Treatment of diabetes mellitus

ABSTRACT

The present invention provides a method of treating insulin-dependent diabetes mellitus in a subject, comprising administering to the subject a therapeutically effective amount of a Janus kinase inhibitor, or a pharmaceutically acceptable salt or ester thereof, or a therapeutically effective amount of intravenous immunoglobulin, or a therapeutically effective amount of a therapeutic agent that destroys B lymphocytes, or a combination thereof. The present invention also provides kits containing the same.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.16/108,937, filed on Aug. 22, 2018, which claims the benefit of U.S.Provisional Patent Application No. 62/548,541, filed on Aug. 22, 2017,and U.S. Provisional Patent Application No. 62/620,135, filed on Jan.22, 2018, the contents of these applications are incorporated byreference in their entireties.

FIELD OF THE INVENTION

The invention relates to treatments of insulin-dependent diabetesmellitus (IDDM).

BACKGROUND OF THE INVENTION

Insulin-dependent diabetes mellitus (IDDM), also known as type Idiabetes, is characterized by reduced insulin production andhyperglycemia, i.e., high blood glucose levels, which ultimately resultsin a variety of early symptoms in humans, including increased thirst,frequent urination, extreme hunger, unintended weight loss, fatigue andblurred vision. Untreated, IDDM can ultimately lead to tissue damage,resulting in increased risk of heart attacks and strokes, neuropathy,retinopathy, kidney failure and, ultimately, death. IDDM is one of themost prevalent metabolic disorders in the world. In the United States,approximately one in 300 to 400 people are affected by this disease.Some studies suggest that the incidence of IDDM in the United States iscontinuing to rise.

Different therapies have been employed for treating IDDM. By far themost commonly employed therapy for the clinical symptoms of IDDM isexogenous insulin replacement. However, while insulin replacementtherapy allows most IDDM patients to lead somewhat normal lives, thistherapy is imperfect and does not completely restore metabolichomeostasis. As a result, severe complications including dysfunctions ofthe eye, kidney, heart, and other organs are common in diabetic patientsundergoing insulin replacement therapy. See U.S. Pat. No. 6,207,159,which is hereby incorporated by reference in its entirety.

Another common treatment for the clinical symptoms of IDDM is pancreaticor beta-islet cell transplantation. However, the insulin-producingbeta-cells of transplanted tissues are often rapidly destroyed by thesame autoimmune response which previously destroyed the patient's ownpancreatic tissue. Therefore, the use of immune-suppressants aftertransplantation is common, carrying with it the adverse side effectsdescribed above. See U.S. Pat. No. 6,207,159, which is herebyincorporated by reference in its entirety.

There remains a need for improved treatments of IDDM. The presentinvention addresses this need.

SUMMARY OF THE INVENTION

The present invention provides a method of treating insulin-dependentdiabetes mellitus in a subject, comprising administering to the subjecta therapeutically effective amount of a Janus kinase inhibitor, or apharmaceutically acceptable salt or ester thereof, or a therapeuticallyeffective amount of intravenous immunoglobulin, or a therapeuticallyeffective amount of a therapeutic agent that destroys B lymphocytes, ora combination thereof.

In some embodiments of the present invention, the method comprisesadministering to the subject a therapeutically effective amount of aJanus kinase inhibitor, or a pharmaceutically acceptable salt or esterthereof, and a therapeutically effective amount of intravenousimmunoglobulin.

In some embodiments of the present invention, the method comprisesadministering to the subject a therapeutically effective amount of aJanus kinase inhibitor, or a pharmaceutically acceptable salt or esterthereof, and a therapeutically effective amount of a therapeutic agentthat destroys B lymphocytes.

In some embodiments of the present invention, the method comprisesadministering to the subject a therapeutically effective amount ofintravenous immunoglobulin and a therapeutically effective amount of atherapeutic agent that destroys B lymphocytes.

In some embodiments of the present invention, the method comprisesadministering a therapeutically effective amount of a Janus kinaseinhibitor, or a pharmaceutically acceptable salt or ester thereof, and atherapeutically effective amount of intravenous immunoglobulin, and atherapeutically effective amount of a therapeutic agent that destroys Blymphocytes.

In some embodiments of the present invention, the Janus kinaseinhibitor, or a pharmaceutically acceptable salt or ester thereof, isselected from the group consisting of a JAK1/3 inhibitor and a JAK3inhibitor.

In some embodiments of the present invention, the Janus kinaseinhibitor, or a pharmaceutically acceptable salt or ester thereof, istofacitinib.

In some embodiments of the present invention, the Janus kinaseinhibitor, or a pharmaceutically acceptable salt or ester thereof, istofacitinib citrate.

In some embodiments of the present invention, the therapeutic agent thatdestroys B lymphocytes is a therapeutic agent that binds to Blymphocytes.

In some embodiments of the present invention, the therapeutic agent thatdestroys B lymphocytes is an antibody agent.

In some embodiments of the present invention, the antibody agent is ananti-CD20 antibody agent.

In some embodiments of the present invention, the anti-CD20 antibodyagent is associated with a payload entity.

In some embodiments of the present invention, the payload entity is atherapeutic agent.

In some embodiments of the present invention, the anti-CD20 antibodyagent is an antibody or fragment thereof.

In some embodiments of the present invention, the anti-CD20 antibodyagent comprises amino acid sequences substantially identical to the CDRsof rituximab.

In some embodiments of the present invention, the anti-CD20 antibodyagent is rituximab or a fragment thereof.

In some embodiments of the present invention, the anti-CD20 antibodyagent is rituximab.

In some embodiments of the present invention, the Janus kinaseinhibitor, or a pharmaceutically acceptable salt or ester thereof, istofacitinib citrate and the therapeutic agent that destroys Blymphocytes is rituximab.

In some embodiments of the present invention, the subject has beendiagnosed with a viral infection.

In some embodiments of the present invention, the viral infection iscaused by infection with Coxsackievirus.

In some embodiments of the present invention, tofacitinib citrate isadministered orally.

In some embodiments of the present invention, tofacitinib citrate isadministered as a tablet.

In some embodiments of the present invention, the tablet is animmediate-release tablet, comprising one or more binders, or one or morediluents, or one or more disintegrants, or one or more lubricants, orcombinations thereof.

In some embodiments of the present invention, the immediate-releasetablet comprises tofacitinib citrate and the excipients microcrystallinecellulose, lactose monohydrate, croscarmellose sodium, magnesiumstearate, HPMC 2910/Hypromellose 6 cP, titanium dioxide,macrogol/PEG3350, and triacetin.

In some embodiments of the present invention, the immediate-releasetablet comprises about 8 mg tofacitinib citrate.

In some embodiments of the present invention, the immediate-releasetablet comprises 8 mg tofacitinib citrate.

In some embodiments of the present invention, the tablet is anextended-release tablet, comprising one or more binders, or one or morediluents, or one or more disintegrants, or one or more lubricants, orcombinations thereof.

In some embodiments of the present invention, the extended-releasetablet comprises tofacitinib citrate and the excipients sorbitol,hydroxyethyl cellulose, copovidone, magnesium stearate, celluloseacetate, hydroxypropyl cellulose, HPMC 2910/Hypromellose, titaniumdioxide, triacetin, and red iron oxide.

In some embodiments of the present invention, the extended-releasetablet comprises about 17.77 mg tofacitinib citrate.

In some embodiments of the present invention, the extended-releasetablet comprises 17.77 mg tofacitinib citrate.

In some embodiments of the present invention, the intravenousimmunoglobulin is administered as a sterile solution for injectioncomprising from 9%-11% protein in 0.16-0.24 M glycine.

In some embodiments of the present invention, rituximab is administeredintravenously.

In some embodiments of the present invention, rituximab to beadministered is formulated in polysorbate 80 (0.7 mg/mL), sodiumchloride (9 mg/mL), sodium citrate dihydrate (7.35 mg/mL), and water, ata pH of 6.5.

In some embodiments of the present invention, rituximab to beadministered is formulated at a concentration of 10 mg/ml.

In some embodiments of the present invention, rituximab to beadministered is diluted to a final concentration of 1 mg/mL to 4 mg/mLin an infusion bag containing either 0.9% Sodium Chloride, USP, or 5%Dextrose in Water, USP, before administration.

In some embodiments of the present invention, tofacitinib citrate isadministered at a dose of 8 or 16 mg twice daily.

In some embodiments of the present invention, the intravenousimmunoglobulin is administered at a dose of 1 to 2 mg per kg weight ofthe subject every 1 to 3 weeks.

In some embodiments of the present invention, the intravenousimmunoglobulin is administered at a dose of 2 mg per kg weight of thesubject on the first day of treatment followed by doses of 1 mg per kgweight of the subject on the second and third days, and wherein theintravenous immunoglobulin is administered at a dose of 1 to 2 mg per kgweight of the subject every 1 to 3 weeks thereafter.

In some embodiments of the present invention, rituximab is administeredat a dose of 375 mg/m2 surface of the subject once per week.

In some embodiments of the present invention, rituximab is administeredat a dose of 375 mg/m2 surface of the subject once per week for a periodof three weeks.

The present invention provides a method of treating insulin-dependentdiabetes mellitus in a subject, comprising administering to the subjecttwice daily two immediate-release tablets each comprising 8 mg oftofacitinib citrate and the excipients microcrystalline cellulose,lactose monohydrate, croscarmellose sodium, magnesium stearate, HPMC2910/Hypromellose 6 cP, titanium dioxide, macrogol/PEG3350, andtriacetin, and administering to the subject 1 to 2 mg intravenousimmunoglobulin per kg weight of subject every 1 to 3 weeks.

The present invention provides a method of treating insulin-dependentdiabetes mellitus in a subject, comprising administering to the subjecttwice daily two immediate-release tablets each comprising 8 mg oftofacitinib citrate; administering to the subject intravenousimmunoglobulin at a dose of 2 mg per kg weight of the subject on thefirst day of treatment followed by doses of 1 mg per kg weight of thesubject on the second and third days, and wherein the intravenousimmunoglobulin is administered at a dose of 1 mg per kg weight of thesubject every 3 weeks thereafter for a total of 5 to 6 months; andadministering to the subject rituximab at a dose of 375 mg/m2 surface ofthe subject once per week for a period of three weeks.

The present invention provides a kit for the treatment ofinsulin-dependent diabetes mellitus in a subject, comprising a Januskinase inhibitor, or a pharmaceutically acceptable salt or esterthereof, and intravenous immunoglobulin.

The present invention provides a kit for the treatment ofinsulin-dependent diabetes mellitus in a subject, comprising a Januskinase inhibitor, or a pharmaceutically acceptable salt or esterthereof, and a therapeutic agent that destroys B lymphocytes.

The present invention provides a kit for the treatment ofinsulin-dependent diabetes mellitus in a subject, comprising a Januskinase inhibitor, or a pharmaceutically acceptable salt or esterthereof, and intravenous immunoglobulin, and a therapeutic agent thatdestroys B lymphocytes.

In some embodiments of the present kit invention, the Janus kinaseinhibitor, or a pharmaceutically acceptable salt or ester thereof, istofacitinib citrate; and wherein the therapeutic agent that destroys Blymphocytes is rituximab.

The present invention provides a kit for the treatment ofinsulin-dependent diabetes mellitus in a subject, comprising intravenousimmunoglobulin and a therapeutic agent that destroys B lymphocytes.

The present invention provides a method of treating insulin-dependentdiabetes mellitus in a subject, comprising administering to the subjecttofacitinib citrate; and administering to the subject intravenousimmunoglobulin; and administering to the subject rituximab.

In some embodiments of the present invention, the tofacitinib citrate isadministered at a dose from 4 mg to 64 mg per day; and wherein theintravenous immunoglobulin is administered at a dose of from 0.2 mg to100 mg per kg weight of the subject every 1 to 4 weeks; and wherein therituximab is administered at a dose of from 50 mg/m2 to 700 mg/m2surface of the subject every 1 to 4 weeks.

In some embodiments of the present invention, the tofacitinib citrate isadministered as immediate-release tablet or extended-release tabletcomprising from 2 mg to 30 mg tofacitinib citrate; and wherein theintravenous immunoglobulin is administered as a sterile solution forinjection comprising from 2%-50% protein; and wherein the rituximab isadministered intravenously at a concentration of 0.2 mg/mL to 20 mg/mL.

In some embodiments of the present invention, the tofacitinib citrate isadministered at a dose from about 8 mg to about 32 mg per day as animmediate-release tablet comprising about 8 mg tofacitinib citrate or asan extended-release tablet comprising about 17.77 mg tofacitinib citrateor both; and wherein the intravenous immunoglobulin is administered as asterile solution for injection comprising from 5%-20% protein at a doseof from 1 mg to 2 mg per kg weight of the subject every 1 to 4 weeks;and wherein the rituximab is administered intravenously at aconcentration of 1 mg/mL to 4 mg/mL at a dose of 375 mg/m2 surface ofthe subject once per week.

In some embodiments of the present invention, the tofacitinib citrate isadministered at a dose of 32 mg per day as an immediate-release tabletcomprising about 8 mg tofacitinib citrate; and wherein the intravenousimmunoglobulin is administered at a dose of 1 mg per kg weight of thesubject every 3 weeks for a total of 5 to 6 months, and whereinintravenous immunoglobulin is administered at a dose of 2 mg per kgweight of the subject on a first day of treatment followed by doses of 1mg per kg weight of the subject on second and third days of treatment;and wherein the rituximab is administered for a period of three weeks.

The present invention provides a method of treating insulin-dependentdiabetes mellitus in a subject, comprising administering to the subjecttofacitinib citrate; and administering to the subject intravenousimmunoglobulin.

In some embodiments of the present invention, the tofacitinib citrate isadministered at a dose from 4 mg to 64 mg per day; and wherein theintravenous immunoglobulin is administered at a dose of from 0.2 mg to100 mg per kg weight of the subject every 1 to 4 weeks.

In some embodiments of the present invention, the tofacitinib citrate isadministered as immediate-release tablet or extended-release tabletcomprising from 2 mg to 30 mg tofacitinib citrate; and wherein theintravenous immunoglobulin is administered as a sterile solution forinjection comprising from 2%-50% protein.

In some embodiments of the present invention, the tofacitinib citrate isadministered at a dose from about 8 mg to about 32 mg per day as animmediate-release tablet comprising about 8 mg tofacitinib citrate or asan extended-release tablet comprising about 17.77 mg tofacitinib citrateor both; and wherein the intravenous immunoglobulin is administered as asterile solution for injection comprising from 5%-20% protein at a doseof from 1 mg to 2 mg per kg weight of the subject every 1 to 4 weeks.

In some embodiments of the present invention, the tofacitinib citrate isadministered at a dose of 32 mg per day as an immediate-release tabletcomprising about 8 mg tofacitinib citrate; and wherein the intravenousimmunoglobulin is administered at a dose of 1 mg per kg weight of thesubject every 3 weeks for a total of 5 to 6 months, and whereinintravenous immunoglobulin is administered at a dose of 2 mg per kgweight of the subject on a first day of treatment followed by doses of 1mg per kg weight of the subject on second and third days of treatment.

In some embodiments of the present invention, therapeutically effectiveamounts of tofacitinib citrate, and intravenous immunoglobulin, andrituximab are administered.

In some embodiments of the present invention, therapeutically effectiveamounts of tofacitinib citrate and intravenous immunoglobulin, areadministered.

In some embodiments of the present invention, the subject is in need oftreatment.

The present invention provides a therapeutically effective amount of aJanus kinase inhibitor, or a pharmaceutically acceptable salt or esterthereof, or a therapeutically effective amount of intravenousimmunoglobulin, or a therapeutically effective amount of a therapeuticagent that destroys B lymphocytes, or a combination thereof, for use inthe treatment of insulin-dependent diabetes mellitus in a subject.

The present invention provides for the use of a therapeuticallyeffective amount of a Janus kinase inhibitor, or a pharmaceuticallyacceptable salt or ester thereof, or a therapeutically effective amountof intravenous immunoglobulin, or a therapeutically effective amount ofa therapeutic agent that destroys B lymphocytes, or a combinationthereof, for the manufacture of a medicament for the treatment ofinsulin-dependent diabetes mellitus in a subject.

The present invention provides tofacitinib and intravenousimmunoglobulin for use in the treatment of insulin-dependent diabetesmellitus in a subject, wherein two immediate-release tablets eachcomprising 8 mg of tofacitinib citrate and the excipientsmicrocrystalline cellulose, lactose monohydrate, croscarmellose sodium,magnesium stearate, HPMC 2910/Hypromellose 6 cP, titanium dioxide,macrogol/PEG3350, and triacetin are administered to the subject twicedaily; and wherein 1 to 2 mg intravenous immunoglobulin per kg weight ofthe subject is administered to the subject every 1 to 3 weeks.

The present invention provides tofacitinib and intravenousimmunoglobulin and rituximab for use in the treatment ofinsulin-dependent diabetes mellitus in a subject, wherein twoimmediate-release tablets each comprising 8 mg of tofacitinib citrateare administered to the subject twice daily; wherein intravenousimmunoglobulin is administered to the subject at a dose of 2 mg per kgweight of the subject on the first day of treatment followed by doses of1 mg per kg weight of the subject on the second and third days, andwherein the intravenous immunoglobulin is administered at a dose of 1 mgper kg weight of the subject every 3 weeks thereafter for a total of 5to 6 months; and wherein rituximab is administered to the subject at adose of 375 mg/m² surface of the subject once per week for a period ofthree weeks.

The present invention provides the use of tofacitinib and intravenousimmunoglobulin for the manufacture of a medicament for the treatment ofinsulin-dependent diabetes mellitus in a subject, wherein twoimmediate-release tablets each comprising 8 mg of tofacitinib citrateand the excipients microcrystalline cellulose, lactose monohydrate,croscarmellose sodium, magnesium stearate, HPMC 2910/Hypromellose 6 cP,titanium dioxide, macrogol/PEG3350, and triacetin are administered tothe subject twice daily; and wherein 1 to 2 mg intravenousimmunoglobulin per kg weight of the subject is administered to thesubject every 1 to 3 weeks.

The present invention provides the use of tofacitinib and intravenousimmunoglobulin and rituximab for the manufacture of a medicament for thetreatment of insulin-dependent diabetes mellitus in a subject, whereintwo immediate-release tablets each comprising 8 mg of tofacitinibcitrate are administered to the subject twice daily; wherein intravenousimmunoglobulin is administered to the subject at a dose of 2 mg per kgweight of the subject on the first day of treatment followed by doses of1 mg per kg weight of the subject on the second and third days, andwherein the intravenous immunoglobulin is administered at a dose of 1 mgper kg weight of the subject every 3 weeks thereafter for a total of 5to 6 months; and wherein rituximab is administered to the subject at adose of 375 mg/m² surface of the subject once per week for a period ofthree weeks.

In some embodiments of the present invention, the use is as in any ofthe embodiments of the present invention set forth herein.

DETAILED DESCRIPTION OF THE INVENTION

Terms used herein shall be accorded the following defined meanings,unless otherwise indicated elsewhere herein.

The term “a” should be understood to mean “at least one”; and the terms“about” and “approximately” should be understood to permit standardvariation as would be understood by those of ordinary skill in the art;and where ranges are provided, endpoints are included.

Administration: As used herein, the term “administration” or“administering” refers to the administration of a compound, composition,dosage form and the like to a patient, subject or system. Administrationto a subject (e.g., to a human) may be facilitated by any appropriateroute. For example, in some embodiments of the present invention,administration may be bronchial (including by bronchial instillation),buccal, enteral, interdermal, intra-arterial, intradermal, intragastric,intramedullary, intramuscular, intranasal, intraperitoneal, intrathecal,intravenous, intraventricular, mucosal, nasal, oral, rectal,subcutaneous, sublingual, topical, tracheal (including by intratrachealinstillation), transdermal, vaginal and/or intravitreal. In someembodiments of the present invention, administration may involveintermittent dosing. In some embodiments of the present invention,administration may involve continuous dosing (e.g., perfusion) for atleast a selected period of time.

Affinity: As is known in the art, “affinity” is a measure of thetightness with which a particular ligand binds to its binding partner,for example a receptor. Affinities can be measured in various waysgenerally known to the person having ordinary skill in the art. In someembodiments of the present invention, affinity is measured by aquantitative assay. In some such embodiments, binding partnerconcentration may be fixed to be in excess of ligand concentration so asto mimic physiological conditions. Alternatively or additionally, insome embodiments of the present invention, binding partner concentrationand/or ligand concentration may be varied. In some such embodiments,affinity may be compared to a reference under comparable conditions(e.g., concentrations).

Agent: The term “agent” as used herein may refer to a compound or entityof any chemical class including, for example, small molecules,polypeptides, nucleic acids, saccharides, lipids, metals, orcombinations thereof. As will be clear from context, in someembodiments, an agent can be or comprise a cell or organism, or afraction, extract, or component thereof. In some embodiments of thepresent invention, an agent is or comprises a natural product in that itis found in and/or is obtained from nature. In some embodiments of thepresent invention, an agent is or comprises one or more entities that isman-made in that it is designed, engineered, and/or produced throughaction of the hand of man and/or is not found in nature. In someembodiments of the present invention, an agent may be utilized inisolated or pure form; in some embodiments of the present invention, anagent may be utilized in crude form. Some particular embodiments ofagents that may be utilized in accordance with the present inventioninclude small molecules, antibodies, antibody fragments, aptamers,nucleic acids (e.g., siRNAs, shRNAs, DNA/RNA hybrids, antisenseoligonucleotides, ribozymes), peptides, peptide mimetics, etc.

Animal: As used herein, the term “animal” refers to any member of theanimal kingdom, including humans.

Antibody: As used herein, the term “antibody” refers to a polypeptidethat includes canonical immunoglobulin sequence elements sufficient toconfer specific binding to a particular target antigen. As is known inthe art, intact antibodies as produced in nature are typicallyapproximately 150 kD tetrameric agents comprised of two identical heavychain polypeptides (about 50 kD each) and two identical light chainpolypeptides (about 25 kD each) that associate with each other into whatis commonly referred to as a “Y-shaped” structure. Each heavy chain iscomprised of at least four domains—an amino-terminal variable (VH)domain (located at the tips of the Y structure), followed by threeconstant domains: CH1, CH2, and the carboxy-terminal CH3 (located at thebase of the Y's stem). A short region, known as the “switch”, connectsthe heavy chain variable and constant regions. The “hinge” connects CH2and CH3 domains to the rest of the antibody. Two disulfide bonds in thishinge region connect the two heavy chain polypeptides to one another inan intact antibody. Each light chain is comprised of two domains—anamino-terminal variable (VL) domain, followed by a carboxy-terminalconstant (CL) domain, separated from one another by another “switch”.Intact antibody tetramers are comprised of two heavy chain-light chaindimers in which the heavy and light chains are linked to one another bya single disulfide bond; two other disulfide bonds connect the heavychain hinge regions to one another, so that the dimers are connected toone another and the tetramer is formed. Naturally-produced antibodiesmay also be glycosylated, typically on the CH2 domain. Each variabledomain contains three hypervariable loops known as complementdetermining regions (CDR1, CDR2, and CDR3) and four somewhat invariantframework regions (FR1, FR2, FR3, and FR4). When natural antibodiesfold, the FR regions form the beta sheets that provide the structuralframework for the domains, and the CDR loop regions from both the heavyand light chains are brought together in three-dimensional space so thatthey create a single hypervariable antigen-binding site located at thetip of the Y structure. Amino acid sequence comparisons among antibodypolypeptide chains have defined two light chain (κ and λ) classes,several heavy chain (e.g., μ, γ, α, ε, δ) classes, and certain heavychain subclasses (a1, a2, γ

, γ2, γ3, and γ4). Antibody classes (IgA [including IgA1, IgA2], IgD,IgE, IgG [including IgG1, IgG2, IgG3, IgG4], IgM) are defined based onthe class of the utilized heavy chain sequences. The Fc region ofnaturally-occurring antibodies binds to elements of the complementsystem, and also to receptors on effector cells, including for exampleeffector cells that mediate cytotoxicity. As is known in the art,affinity and/or other binding attributes of Fc regions for Fc receptorscan be modulated through glycosylation or other modification. Forpurposes of the present invention, in certain embodiments, anypolypeptide or complex of polypeptides that includes sufficientimmunoglobulin domain sequences as found in natural antibodies can bereferred to and/or used as an “antibody”, whether such polypeptide isnaturally produced (e.g., generated by an organism reacting to anantigen), or produced by recombinant engineering, chemical synthesis, orother artificial system or methodology. In some embodiments of thepresent invention, an antibody is polyclonal; in some embodiments of thepresent invention, an antibody is monoclonal. In some embodiments of thepresent invention, an antibody has constant region sequences that arecharacteristic of mouse, rabbit, primate, or human antibodies. In someembodiments of the present invention, antibody sequence elements arehumanized, primatized, chimeric, etc., as is known in the art. Moreover,the term antibody as used herein, will be understood to refer inappropriate embodiments (unless otherwise stated or clear from context)to any of the art-known or developed constructs or formats for capturingantibody structural and functional features in alternative presentation.In some embodiments of the present invention, an antibody may lack acovalent modification (e.g., attachment of a glycan) that it would haveif produced naturally. In some embodiments of the present invention, anantibody may contain a covalent modification (e.g., attachment of aglycan, a payload [e.g., a detectable moiety, a therapeutic moiety, acatalytic moiety, etc.]), or other pendant group (e.g., poly-ethyleneglycol, etc.). As used herein, the term antibody includes antibodyfragments, such as, but not limited to, Fc and Fab fragments.

Antibody agent: As used herein, the term “antibody agent” refers to anagent that binds to one or more antigens. In some embodiments of thepresent invention, the term encompasses any polypeptide withimmunoglobulin structural elements sufficient to confer specificbinding, such as, but not limited to, antibodies and antibody fragments.Suitable antibody agents include, but are not limited to, humanantibodies, humanized antibodies, primatized antibodies, mouseantibodies, rabbit antibodies, rat antibodies, sheep antibodies, donkeyantibodies, horse antibodies, chimeric antibodies, bi-specificantibodies, conjugated antibodies (i.e., antibodies conjugated or fusedto other proteins, radiolabels, cytotoxins), Small ModularImmunoPharmaceuticals (“SMIPs™”), single chain antibodies (scAbs),cameloid antibodies, and antibody fragments. As used herein, the termantibody agent also includes intact monoclonal antibodies, polyclonalantibodies, single domain antibodies (e.g., shark single domainantibodies (e.g., IgNAR or fragments thereof)), multispecific antibodies(e.g. bi-specific antibodies, zybodies, etc.) formed from at least twointact antibodies, and antibody fragments so long as they exhibit thedesired biological activity. In some embodiments of the presentinvention, the term antibody agent encompasses stapled peptides. In someembodiments of the present invention, the term antibody agentencompasses one or more antibody-like binding peptidomimetics. In someembodiments of the present invention, the term encompasses one or moreantibody-like binding scaffold proteins. In come embodiments, the termencompasses monobodies or adnectins. In some embodiments of the presentinvention, an antibody agent is or comprises a polypeptide whose aminoacid sequence includes one or more structural elements recognized bythose skilled in the art as a complementarity determining region (CDR).In some embodiments of the present invention, an antibody agent is orcomprises a polypeptide whose amino acid sequence includes at least oneCDR (e.g., at least one heavy chain CDR and/or at least one light chainCDR) that is substantially identical to one found in a referenceantibody. In some embodiments of the present invention, an included CDRis substantially identical to a reference CDR in that it is eitheridentical in sequence or contains between 1-5 amino acid substitutionsas compared with the reference CDR. In some embodiments of the presentinvention an included CDR is substantially identical to a reference CDRin that it shows at least 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%,94%, 95%, 96%, 97%, 98%, 99%, or 100% amino acid sequence identity withthe reference CDR. In some embodiments of the present invention, anantibody agent is or comprises a polypeptide whose amino acid sequenceincludes structural elements recognized by those skilled in the art asan immunoglobulin variable domain. In some embodiments of the presentinvention, an antibody agent is a polypeptide protein having a bindingdomain which is homologous or largely homologous to animmunoglobulin-binding domain. The term antibody agent includes chimericantigen receptors. An anti-CD20 antibody agent is an antibody agent thatspecifically binds to the CD20 antigen.

Antibody fragment: As used herein, an “antibody fragment” includes aportion of an intact antibody, such as, for example, the antigen-bindingor variable region of an antibody. Examples of antibody fragmentsinclude, but are not limited to, a Fab fragment, a Fab′ fragment, aF(ab′)2 fragment, a scFv fragment, a Fv fragment, a dsFv diabody, a dAbfragment, a Fd′ fragment, a Fd fragment, and an isolated complementaritydetermining region (CDR) region, as well as triabodies, tetrabodies,linear antibodies, single-chain antibody molecules, and multi specificantibodies formed from antibody fragments. Fv fragments are thecombination of the variable regions of the immunoglobulin heavy andlight chains, and ScFv proteins are recombinant single chain polypeptidemolecules in which immunoglobulin light and heavy chain variable regionsare connected by a peptide linker. In some embodiments of the presentinvention, an antibody fragment contains sufficient amino acid sequenceof the parent antibody of which it is a fragment that it binds to thesame antigen as does the parent antibody; in some embodiments of thepresent invention, a fragment binds to the antigen with a comparableaffinity to that of the parent antibody and/or competes with the parentantibody for binding to the antigen. An antibody fragment may beproduced by any means. For example, an antibody fragment may beenzymatically or chemically produced by fragmentation of an intactantibody and/or it may be recombinantly produced from a gene encodingthe partial antibody sequence. Alternatively or additionally, anantibody fragment may be wholly or partially synthetically produced. Anantibody fragment may optionally comprise a single chain antibodyfragment. Alternatively or additionally, an antibody fragment maycomprise multiple chains that are linked together, for example, bydisulfide linkages. An antibody fragment may optionally comprise amulti-molecular complex. A functional antibody fragment typicallycomprises at least about 50 amino acids and more typically comprises atleast about 200 amino acids

Antigen: An “antigen” is a molecule or entity that (i) elicits an immuneresponse; and/or (ii) is specifically bound by a T cell receptor (e.g.,when presented by an MHC molecule) or an antibody (e.g., produced by a Bcell), for example when exposed or administered to an organism. In someembodiments of the present invention, an antigen elicits a humoralresponse (e.g., including production of antigen-specific antibodies) inan organism; alternatively or additionally, in some embodiments of thepresent invention, an antigen elicits a cellular response (e.g.,involving T-cells whose receptors specifically interact with theantigen) in an organism.

Binding: It will be understood that the term “binding”, as used herein,typically refers to a non-covalent association between or among two ormore entities. “Direct” binding involves physical contact betweenentities or moieties; indirect binding involves physical interaction byway of physical contact with one or more intermediate entities. Bindingbetween two or more entities can typically be assessed in any of avariety of contexts—including where interacting entities or moieties arestudied in isolation or in the context of more complex systems (e.g.,while covalently or otherwise associated with a carrier entity and/or ina biological system or cell).

CD20: The term “CD20” or “CD20 antigen”, as used herein, refers to theCD20 antigen, which is expressed for example on the surfaceB-lymphocytes.

Combination therapy: The term “combination therapy”, as used herein,refers to those situations in which two or more different therapeuticagents are administered in combination with each other, i.e., inoverlapping or sequential regimens so that the subject is simultaneouslyor sequentially exposed to the two or more therapeutic agents. When onetherapeutic agent is administered “in combination with” one or moreother therapeutic agents, it is not intended to imply that thetherapeutic agents must be administered at the same time and/orformulated for delivery together in one dosage unit, although thesemethods of delivery are within the scope of the invention. Compositionscontaining a therapeutic agent can be administered concurrently with,prior to, or subsequent to, one or more other compositions containing adifferent therapeutic agent. In general, each therapeutic agent will beadministered at a dose and/or on a time schedule determined to beoptimal for that agent.

Dosage unit: As used herein, the term “dosage unit” refers to aphysically discrete unit of one or more active pharmaceuticalingredients (e.g., a therapeutic or diagnostic or both) foradministration to a subject. Each dosage unit contains a predeterminedquantity of one or more active pharmaceutical ingredients. In someembodiments of the present invention, such quantity is a dose amount (ora whole fraction thereof) appropriate for administration in accordancewith a dosing regimen that has been determined to correlate with adesired or beneficial outcome when administered to a relevantpopulation. Those of ordinary skill in the art appreciate that the totalamount of a therapeutic agent administered to a particular subject isdetermined by one or more attending physicians and may involveadministration of multiple dosage units.

Dosage form: As used herein, the term “dosage form” refers to the typeof a dosage unit, non-limiting examples of which are tablets, capsules,pills, solutions, suspensions, emulsion, powders, sustained-releaseformulations and the like.

Dosing regimen: As used herein, the term “dosing regimen” refers to aset of doses (typically more than one) that are administeredindividually to a subject, typically separated by periods of time. Insome embodiments of the present invention, a given therapeutic agent hasa recommended dosing regimen, which may involve one or more doses. Insome embodiments of the present invention, a dosing regimen comprises aplurality of doses each of which are separated from one another by atime period of the same length; in some embodiments of the presentinvention, a dosing regimen comprises a plurality of doses and at leasttwo different time periods separating individual doses. In someembodiments of the present invention, all doses within a dosing regimenhave the same amount of therapeutic agent (i.e., the same dose amount).In some embodiments of the present invention, different doses within adosing regimen have different amounts of therapeutic agent (i.e.,different dose amounts). In some embodiments of the present invention, adosing regimen comprises a first dose in a first dose amount, followedby one or more additional doses in a second dose amount different fromthe first dose amount. In some embodiments of the present invention, adosing regimen comprises a first dose in a first dose amount, followedby one or more additional doses in a second dose amount that is the sameas the first dose amount. In some embodiments of the present invention,a dosing regimen is correlated with a desired or beneficial outcome whenadministered across a relevant population (i.e., is a therapeutic dosingregimen).

Human: In some embodiments of the present invention, a human is anembryo, a fetus, an infant, a child, a teenager, or an adult.

Intravenous immunoglobulin: As used herein, the term “intravenousimmunoglobulin” (also known as immunoglobulin therapy, normal humanimmunoglobulin, NHIG and IVIG) refers to a preparation of pooledimmunoglobulins from the plasma of a plurality of blood donors forintravenous administration. In some embodiments of the presentinvention, the intravenous immunoglobulin comprises primarily IgG.

Janus kinase inhibitor: As used herein, the term “Janus kinaseinhibitor” or “JAK inhibitor” refers to any agent (for example a smallmolecule compound) that interacts with and thereby reduces the signalingactivity of a Janus kinase (JAK), preferably by reducing its enzymaticactivity. It is thought that Janus kinase 3 (JAK3) primarily signals incombination with Janus kinase 1 (JAK1) in living cells. As used herein,the term “JAK1/3 inhibitor” refers to a Janus kinase inhibitor thatreduces the signaling activity of the pair of JAK1 and JAK3 in livingcells. As used herein, the term “JAK3 inhibitor” refers to Janus kinaseinhibitor that reduces the signaling activity of JAK3. In someembodiments of the present invention, such reduction of signalingactivity is at least about 50%, at least about 60%, at least about 75%,at least about 90%, at least about 95%, or at least about 99%. In someembodiments of the present invention, the concentration of a JAKinhibitor required to reduce the signaling activity of a JAK is lessthan about 1 μM, less than about 500 nM, less than about 100 nM, lessthan about 50 nM, less than about 10 nM, or less than about 1 nM.Preferably, the concentration of a JAK1/3 inhibitor that is required toreduce the signaling activity of the pair of JAK1 and JAK3 in livingcells is lower than the concentration of the JAK1/3 inhibitor that isrequired to reduce the signaling activity of other pairs of JAKs inliving cells to a comparable extent; in some embodiments of the presentinvention, this concentration is at least about 2-fold, at least about5-fold, at least about 10-fold, at least about 20-fold, at least about50-fold, at least about 100-fold, at least about 500-fold, or at leastabout 1000-fold lower. Preferably, the concentration of the JAK3inhibitor that is required to reduce the signaling activity of JAK3 islower than the concentration of the JAK3 inhibitor that is required toreduce the signaling activity of other JAKs to a comparable extent; insome embodiments of the present invention, this concentration is atleast about 2-fold, at least about 5-fold, at least about 10-fold, atleast about 20-fold, at least about 50-fold, at least about 100-fold, atleast about 500-fold, or at least about 1000-fold lower. In someembodiments of the present invention, the extent by which a JAKinhibitor reduces the signaling activity of a JAK is expressed as theconcentration of the JAK inhibitor needed to reduce the signalingactivity of the JAK by 50%, also expressed as IC₅₀ (nM). Methods tomeasure the reduction of signaling activity of a Janus kinase (JAK), orof a pair of Janus kinases (JAKs) due to the presence of an inhibiterare generally known in the art and thus not provided in detail herein.Non-limiting examples of such methods are in vitro kinase assays and invitro whole blood STAT phosphorylation assays, as described, e.g., inMeyer et al., Journal of Inflammation 7:41 (2010).

Patient: As used herein, the term “patient” refers to any animal (e.g.,mammals such as mice, rats, rabbits, non-human primates, and/or humans)to which a composition, dosage unit or the like provided herein is ormay be administered, e.g., for experimental, diagnostic, prophylactic,cosmetic, and/or therapeutic purposes. In some embodiments of thepresent invention, a patient is a human. In some embodiments of thepresent invention, a patient is suffering from or susceptible to one ormore disorders or conditions. In some embodiments of the presentinvention, a patient displays one or more symptoms of a disorder orcondition. In some embodiments of the present invention, a patient hasbeen diagnosed with one or more disorders or conditions. In someembodiments of the present invention, the disorder or condition is orincludes insulin dependent diabetes mellitus. As used herein, the nounspatient and subject have the same meaning and are used interchangeably.

Pharmaceutical composition: As used herein, the term “pharmaceuticalcomposition” refers to a therapeutic agent that is formulated togetherwith one or more pharmaceutically acceptable carriers. In someembodiments of the present invention, the therapeutic agent is presentin a unit dose amount appropriate for administration in a therapeuticregimen. In some embodiments of the present invention, pharmaceuticalcompositions may be specially formulated for administration in solid orliquid form, including those adapted for the following: oraladministration (for example in the form of tablets (e.g., those targetedfor buccal, sublingual, and systemic absorption), boluses, powders,granules, pastes for application to the tongue); parenteraladministration (for example in the form of subcutaneous, intramuscular,intravenous or epidural injections that may be sterile solutions orsuspensions, or sustained-release formulations); topical administration(for example in the form of a cream, ointment, or a controlled-releasepatch or spray applied to the skin or oral cavity); intravaginal orintrarectal administration (for example in the form of a pessary, cream,or foam); sublingual administration; ocular administration; transdermaladministration; nasal administration; pulmonary administration; oradministration to other mucosal surfaces. As used herein, the termscarrier and excipient have the same meaning and are usedinterchangeably.

Therapeutic agent: As used herein, the term “therapeutic agent” ingeneral refers to any agent that is administered for the purpose oftreating a subject and that may elicit a desired response whenadministered to a subject. The terms therapeutic agent, active agent,active ingredient, active pharmaceutical ingredient and drug have thesame meaning and are used interchangeably herein. Therapeutic agentsinclude but are not limited to Janus kinase inhibitors, intravenousimmunoglobulin and therapeutic agents that destroy B lymphocytes.

Therapeutic agent that destroys B lymphocytes: As used herein, the term“therapeutic agent that destroys B lymphocytes” refers to anytherapeutic agent that, upon administration to a subject, directly orindirectly causes the death or destruction of at least some of thesubject's B lymphocytes. In some embodiments of the present invention,at least about 10, 20, 30, 40, 50, 60, 70, 80 or 90% of the subject's Blymphocytes are destroyed, as determined by standard methods known tothe person having ordinary skill in the art. The terms B lymphocytes andB cells are used interchangeably herein.

Therapeutic regimen: A “therapeutic regimen”, as that term is usedherein, refers to a dosing regimen, or a plurality of dosing regimens,administered to a subject for the purpose of treatment. A therapeuticregimen may comprise the administration of one or more therapeuticagents.

Therapeutically effective amount: As used herein, and unless otherwisespecified herein, a “therapeutically effective amount” of a therapeuticagent is an amount that is sufficient, either by itself or incombination with one or more other therapeutic agents, to partially orcompletely alleviate, ameliorate, relive, inhibit, delay onset of,reduce severity of, and/or reduce incidence of one or more symptoms,features, and/or causes of a particular disease, disorder, and/orcondition, or to partially or completely prevent any of the aforesaidfrom worsening. One or more of the aforesaid effects of a therapeuticagent regarding a disease, disorder, and/or condition may be measured,for example, on the clinical, tissue, cellular and/or molecular level. Aperson skilled in the art would recognize that the therapeuticallyeffective amount, or dose, of the therapeutic agents disclosed hereincan be determined based on the disclosures in this patent application(e.g., the Examples (IDDM biomarkers)) and common knowledge in the art.The term therapeutically effective amount does not require successfultreatment or complete cure. Rather, a therapeutically effective amountmay be an amount that provides only for a partial treatment or cure. Theterm therapeutically effective amount does not require that atherapeutic benefit is achieved in a particular subject. Rather, atherapeutically effective amount may achieve a therapeutic benefit onlyin number of subjects in need of treatment, but not all. In someembodiments of the present invention, reference to a therapeuticallyeffective amount may be a reference to an amount as measured in one ormore specific tissues (e.g., a tissue affected by the disease, disorderor condition) or fluids (e.g., blood, saliva, serum, sweat, tears,urine, etc.). Those of ordinary skill in the art will appreciate that,in some embodiments of the present invention, a therapeuticallyeffective amount may be formulated and/or administered in a singledosage unit and dose, respectively. In some embodiments of the presentinvention, a therapeutically effective amount may be formulated and/oradministered in a plurality of dosage units and doses, respectively, forexample, as part of a dosing regimen.

Tofacitinib: As used herein, the term tofacitinib refers to tofacitinibfree base as well as any pharmaceutically acceptable salt thereof (e.g.,citrate salt).

Treatment: As used herein, the term “treatment” (also “treat” or“treating”) refers to any therapeutic or prophylactic/preventativemeasures the purpose of which is to partially or completely alleviate,ameliorate, relive, inhibit, delay onset of, reduce severity of, and/orreduce incidence of one or more symptoms, features, and/or causes of aparticular disease, disorder, and/or condition, or to partially orcompletely prevent any of the aforesaid from worsening. In someembodiments of the present invention, treatment may be administered to asubject who does not exhibit signs of the relevant disease, disorderand/or condition and/or to a subject who exhibits only early signs ofthe disease, disorder, and/or condition. Alternatively or additionally,in some embodiments of the present invention, treatment may beadministered to a subject who exhibits one or more established signs ofthe relevant disease, disorder and/or condition. In some embodiments ofthe present invention, a subject may be treated who has been diagnosedas suffering from the relevant disease, disorder, and/or condition. Insome embodiments of the present invention, a subject may be treated thatis known to have one or more susceptibility factors that arestatistically correlated with increased risk of development of therelevant disease, disorder, and/or condition. Treatment may comprise theadministration of one or more therapeutic agents to a subject. In someembodiments of the present invention, the term treatment (also “treat”or “treating”) includes actually achieving to partially or completelyalleviate, ameliorate, relive, inhibit, delay onset of, reduce severityof, and/or reduce incidence of one or more symptoms, features, and/orcauses of a particular disease, disorder, and/or condition, or topartially or completely prevent any of the aforesaid from worsening. Aperson having ordinary skill in the art would know how to determinewhether treatment (as defined herein) has occurred based on thedisclosures in this specification and common knowledge in the art.

Insulin-Dependent Diabetes Mellitus (IDDM)

Insulin-dependent diabetes mellitus (IDDM) is characterized by reducedinsulin production and hyperglycemia, i.e., high blood glucose levels.The root cause of IDDM is unknown. However, studies suggest that IDDM iscaused, at least in part, by a T lymphocyte-mediated autoimmune responsethat leads to the destruction of insulin-producing pancreaticbeta-cells. The commonly employed regimens for the treatment ofinsulin-dependent diabetes mellitus (IDDM) are primarily directed toalleviating the symptoms of the disease, and associated with sometimessevere complications and side effects.

The present invention is, in part, based on the recognition that IDDMcan be treated in a subject by administration of a Janus kinase (JAK)inhibitor, intravenous immunoglobulin (IVIG) or a therapeutic agent thatdestroys B lymphocytes (B cells), or by various combinations thereof.

The present invention provides a method of treating insulin-dependentdiabetes mellitus in a subject including administering to the subject atherapeutically effective amount of a Janus kinase inhibitor, or apharmaceutically acceptable salt or ester thereof, therapeuticallyeffective amount of intravenous immunoglobulin, or therapeuticallyeffective amount of a therapeutic agent that destroys B lymphocytes, orcombinations thereof.

In some embodiments of the present invention, the Janus kinaseinhibitor, or a pharmaceutically acceptable salt or ester thereof, is aJAK1/3 inhibitor or JAK3 inhibitor.

In some embodiments of the present invention, the Janus kinaseinhibitor, or a pharmaceutically acceptable salt or ester thereof, is aJAK1/3 inhibitor.

In some embodiments of the present invention, the Janus kinaseinhibitor, or a pharmaceutically acceptable salt or ester thereof, istofacitinib.

In a preferred embodiment of the present invention, the Janus kinaseinhibitor, or a pharmaceutically acceptable salt thereof, is tofacitinibcitrate.

In a preferred embodiment of the present invention, the therapeuticagent that destroys B lymphocytes (B cells) is the antibody rituximab.

JAK-STAT Pathway

Without wishing to be bound by any particular theory, the JAK-STATpathway is believed to be a signal transduction cascade ubiquitousamongst vertebrates. It operates also in some, but not all, invertebrateorganisms, for example Drosophila melanogaster. This pathway transmitsinformation from the extracellular milieu to the cell nucleus, therebyregulating gene expression. JAK-STAT pathway activation stimulates anumber of different basic cellular processes, including cellproliferation, differentiation, migration and apoptosis. These cellularevents are critical to a number of different biological processes,including hematopoiesis, immune development, mammary gland developmentand lactation, adipogenesis, sexually dimorphic growth and otherprocesses. JAK-STAT signaling has been implicated in the mediation ofmany abnormal immune responses such as allergies, asthma, autoimmunediseases such as transplant rejection, rheumatoid arthritis, amyotrophiclateral sclerosis and multiple sclerosis, as well as in solid andhematologic malignancies such as leukemias and lymphomas. See, e.g.,Rawlins et al., Journal of Cell Science 117:1281-1283 (2004), andreferences cited therein.

The JAK-STAT pathway has basically three components, a transmembranereceptor, a Janus kinase (JAK) and two Signal Transducer and Activatorof Transcription (STAT) proteins. According to the current model ofJAK-STAT signaling, engagement of the transmembrane receptor with anextracellular ligand activates JAK proteins associated with thereceptor's cytoplasmic domain. These activated JAK proteins thenphosphorylate the cytoplasmic receptor domain, which in turn results inthe recruitment of STAT proteins to the phosphorylated receptor. Therecruited STATs are then also phosphorylated by the activated,receptor-associated JAK proteins, and each of them then homo- orhetero-dimerizes with another similarly phosphorylated STAT protein.Upon dimerization, the STAT proteins translocate to the cell nucleus andbind to specific DNA recognition sequences in the genome, therebyactivating gene expression. See, e.g., Rane & Reddy, Oncogene19:5662-5679 (2000), and references cited therein.

The cytoplasmic domains of transmembrane receptors associate with JAKsvia JAK binding sites located close to the cell membrane. JAK-mediatedphosphorylation of the intracellular receptor domain creates bindingsites for the Src homology 2 (SH2) domains of STAT proteins. Binding ofSTAT proteins is followed by mostly tyrosine phosphorylation on key STATprotein residues, which then leads to the translocation of thephosphorylated STAT proteins to the cell nucleus.

Many transmembrane receptors and corresponding ligands have beenreported to be involved in JAK-STAT signaling. See, e.g., Murray,Journal of Immunology 178:2623-2629 (2007); Kubler, AustralianPrescriber 37:154-157 (2014); see also O'Shea et al., Annals of theRheumatic Diseases 72:ii111-ii115. For example, interleukin-15 has beenreported to signal through the JAK-STA pathway via activating JAK3. SeeKrolopp et al., Frontiers in Physiology 7:626 (2016).

Janus kinases (JAKs) are non-receptor tyrosine kinases that play acritical role in cytokine signaling in mammals. The mammalian JAK familyof kinases consists of Janus kinase 1 (JAK1), Janus kinase 2 (JAK2),Janus kinase 3 (JAK3) and tyrosine kinase 2 (TYK2). See U.S. Pat. No.7,122,552, which is hereby incorporated by reference in its entirety. Itis thought that JAK proteins do not operate alone, but that eachtransmembrane receptor requires at least two associated JAK proteins inorder to signal. JAK proteins may operate in combinations of two JAKproteins of the same type (e.g., JAK2/JAK2) or of different types (e.g.,JAK1/JAK3). JAK3 is thought to primarily signal in combination withJAK1. See Kubler, Australian Prescriber 37:154-157 (2014); see alsoMurray, Journal of Immunology 178:2623-2629 (2007).

All JAK proteins are characterized by seven so-called Janus homologydomains (JH1-7). JH1 is the JAK proteins' tyrosine kinase domain andincludes conserved residues the phosphorylation of which is importantfor the activation of the proteins' kinase activity. The JH2 domain isstructurally similar to a kinase domain. JH2 does not have kinaseactivity by itself, however, but contributes to the activity of the JH1domain. The JH3 and JH4 domains are homologous to Src-homology-2 (SH2)domains. The JH4 domain in conjunction with the JH5-7 domainsfacilitates the JAK proteins' binding to activated transmembranereceptors.

JAK1 and JAK2 are involved in a broad range of functions including hostdefense, haematopoiesis, neural development and growth. By contrast,JAK3 and TYK2 have a narrower role in the immune response. JAK3 ispredominantly expressed in haematopoietic cells and is critical forsignal transduction of interleukins integral to lymphocyte activation,function and proliferation. See Kubler, Australian Prescriber2014:154-157 (2014).

Many genes have been reported to be regulated via the JAK-STAT pathway,including, for example, GATA3 CD23, Thy, Gp49 and Nfil3. See Murray,Journal of Immunology 178:2623-2629 (2007).

JAK Inhibitors

A number of JAK inhibitors have been reported. For example, the JAK1inhibitor oclacitinib has been approved for the control of pruritusassociated with allergic dermatitis and control of atopic dermatitis indogs at least 12 months of age. See Gonzales et al., Journal ofVeterinary Pharmacology and Therapeutics 37: 317-324 (2014); see alsoPrescribing Information for the Apoquel® Oclacitinib Maleate DrugProduct (revised 2013). The JAK1/JAK2 inhibitor ruxolitinib (INCB018424)has been approved for the treatment of (1) intermediate or high-riskmyelofibrosis, including primary myelofibrosis, post-polycythemia veramyelofibrosis and post-essential thrombocythemia myelofibrosis, and (2)polycythemia vera who have had an inadequate response to or areintolerant of hydroxyurea. See Prescribing Information for the Jakafi®Ruxolitinib Phosphate Drug Product (revised 2016). And the inhibitortofacitinib (CP-690550) has been approved for the treatment of adultpatients with moderately to severely active rheumatoid arthritis whohave had an inadequate response or intolerance to methotrexate.Tofacitinib is currently marketed in its citrate salt form by Pfizerunder the tradename Xeljanz®. See Prescribing Information for the Xeljanz Tofacitinib Citrate Drug Product (revised 2016).

A number of other JAK inhibitors are currently being evaluated inpre-clinical studies or clinical trials, including the followingcompounds: momelotinib (GS-0387, CYT-387), Baricitinib (LY-3009104,previously INCB028050), Filgotinib (GLPG-0634), Gandotinib (LY-2784544),Lestaurtinib (CEP-701), Momelotinib (GS-0387, CYT-387), Pacritinib(SB1518), PF-04965842, Upadacitinib (ABT-494), Peficitinib (ASP015K,JNJ-54781532), Cucurbitacin I (JSI-124), CHZ868, Fedratinib (TG101348;SAR302503), AZD1480; Decernotinib (VX-509; VRT-831509), Solcitinib(GSK-2586184; GLPG-0778), AC430, BMS-911543 and AG490. See, e.g.,Furumoto & Gadina, BioDrugs 27:431-438 (2013).

Without wishing to be bound by any particular theory, tofacitinib hasbeen reported to potently inhibit signaling through JAK1 and JAK3 with5-100 fold selectivity over JAK2 in cellular assays. Tofacitinib hasalso been reported to inhibit recombinant human JAK1, 2, 3 and TYK2 invitro with IC₅₀ (nM) values of 3.2±1.4, 4.1±0.4, 1.6±0.2 and 340±6.0,respectively. These results were interpreted to mean that for each JAKfamily member, tofacitinib competes with ATP for binding to the activesite of the kinase domain. Tofacitinib has also been reported to inhibitcytokine signaling in human whole blood with the followingspecificities: IL-2 (mediated by JAK 1/3 heterodimer, readoutpSTAT5)−IC₅₀ (nM) 28±5, IL-4 (mediated by JAK 1/3 heterodimer, readoutpSTAT6)−IC₅₀ (nM) 50±5, IL-7 (mediated by JAK 1/3 heterodimer, readoutpSTAT5)−IC₅₀ (nM) 38±9, IL-6 (mediated by JAK 1/2 heterodimer, readoutpSTAT1)−IC₅₀ (nM) 54±7, and IL-6 (mediated by JAK 1/2 heterodimer,readout pSTAT3)−IC₅₀ (nM) 367±49. See Meyer et al., Journal ofInflammation 7:41 (2010).

Tofacitinib has been shown to inhibit the in vitro activities ofJAK1/JAK2, JAK1/JAK3, and JAK2/JAK2 combinations with IC₅₀ of 406, 56,and 1377 nM, respectively. The relevance of specific JAK combinations totherapeutic effectiveness is not known. See Prescribing Information forthe Xeljanz® Tofacitinib Citrate Drug Product (revised 2016).

Tofacitinib citrate has been approved for the treatment of adultpatients with moderately to severely active rheumatoid arthritis (RA)who have had an inadequate response or intolerance to methotrexate.Tofacitinib citrate has been approved for use as a monotherapy or incombination with methotrexate or other nonbiologic disease-modifyingantirheumatic drugs (DMARDs).

Tofacitinib citrate is a white to off-white powder with the followingchemical name:(3R,4R)-4-methyl-3-(methyl-7H-pyrrolo[2,3-d]pyrimidin-4-ylamino)-β-oxo-1-piperidinepropanenitrile,2-hydroxy-1,2,3-propanetricarboxylate (1:1). The solubility oftofacitinib citrate in water is 2.9 mg/mL.

Tofacitinib citrate has a molecular weight of 504.5 Daltons (or 312.4Daltons as the tofacitinib free base) and a molecular formula ofC₁₆H₂₀N₆O.C₆H₈O₇. The chemical structure of tofacitinib citrate is asfollows:

Tofacitinib citrate as approved for the treatment of RA is supplied fororal administration as white round, immediate-release film-coatedtablets including 8 mg tofacitinib citrate (equivalent to 5 mgtofacitinib free base). Each tablet of tofacitinib citrate containsadditionally the following excipients: microcrystalline cellulose,lactose monohydrate, croscarmellose sodium, magnesium stearate, HPMC2910/Hypromellose 6 cP, titanium dioxide, macrogol/PEG3350, andtriacetin.

Tofacitinib citrate as approved for the treatment of RA is also suppliedfor oral administration as pink, oval, extended release film-coatedtablets with a drilled hole at one end of the tablet band including17.77 mg tofacitinib citrate (equivalent to 11 mg tofacitinib freebase). Each tablet of tofacitinib citrate contains additionally thefollowing excipients: sorbitol, hydroxyethyl cellulose, copovidone,magnesium stearate, cellulose acetate, hydroxypropyl cellulose, HPMC2910/Hypromellose, titanium dioxide, triacetin, and red iron oxide.

The printing ink on these extended release film-coated tablets containsshellac glaze, ammonium hydroxide, propylene glycol, and ferrosoferricoxide/black iron oxide. See Prescribing Information for the Xeljanz®Tofacitinib Citrate Drug Product (revised 2016).

The recommended dose of tofacitinib citrate for the treatment of RA is 5mg (calculated based on the weight of tofacitinib free base)(immediate-release tablet) twice daily or 11 mg (calculated based on theweight of tofacitinib free base) once daily (extended release tablet).

Tofacitinib citrate is commercially available from Pfizer in the form ofthe Xeljanz® drug product. The synthesis of tofacitinib free base,tofacitinib citrate, and other salts of tofacitinib, as well as themanufacture of the pharmaceutical compositions and dosage formsdisclosed herein are known to those skilled in the art, and describedfor example in U.S. Pat. Nos. 6,956,041; 7,091,208; and 7,265,221; whichare hereby incorporated by reference in their entireties.

Tofacitinib has been reported to primarily inhibit JAK1 and JAK3. Insome embodiments of the present invention, the JAK inhibitor is a JAK3inhibitor. Non-limiting examples of JAK3 inhibitors and theirbioactivity and synthesis are disclosed in U.S. Pat. No. 6,495,556 andU.S. Published Patent Application No. 2004/0198750, which are herebyincorporated by reference in their entireties. The chemical structure ofan exemplary JAK3 inhibitor is provided below:

Each of moieties R2′, R3′, R4′ and R5′ may be H, OH, Br, or CH₃. In apreferred embodiment, moieties R2′, R3′, R4′ and R5′ are H, H, OH and H,respectively. See U.S. Pat. No. 6,495,556 (compound WHI-P131). In apreferred embodiment, moieties R2′, R3′, R4′ and R5′ are H, Br, OH andH, respectively. See U.S. Pat. No. 6,495,556 (compound WHI-P154).

Pharmaceutical Compositions

The present invention also provides pharmaceutical compositionsincluding a JAK inhibitor, which in a non-limiting example istofacitinib citrate, and a pharmaceutically acceptable excipient.

Examples of excipients that can be used in the pharmaceuticalcompositions provided herein are disclosed for example in U.S.Publication No. 2014/0271842 and in Handbook of PharmaceuticalExcipients, 3^(rd) Edition, Edited by A.H. Kibbe, AmericanPharmaceutical Association and Pharmaceutical press (2000), which arehereby incorporated by reference in their entireties.

Other examples of excipients that can be used in the pharmaceuticalcompositions provided herein include, but are not limited to, binders,diluents, disintegrants, and lubricants. Binders suitable for use inpharmaceutical compositions include, but are not limited to, cornstarch, potato starch, or other starches, gelatin, natural and syntheticgums such as acacia, sodium alginate, alginic acid, other alginates,powdered tragacanth, guar gum, cellulose and its derivatives (e.g.,ethyl cellulose, cellulose acetate, carboxymethyl cellulose calcium,sodium carboxymethyl cellulose), polyvinyl pyrrolidone, methylcellulose, pre gelatinized starch, hydroxypropyl methyl cellulose,(e.g., Nos. 2208, 2906, 2910), microcrystalline cellulose, and mixturesthereof.

Examples of diluents suitable for use in the pharmaceutical compositionsprovided herein include, but are not limited to, calcium carbonate(e.g., granules or powder), microcrystalline cellulose, powderedcellulose, dextrates, kaolin, mannitol, silicic acid, sorbitol, starch,pre gelatinized starch, and mixtures thereof. The binder or diluent inpharmaceutical compositions provided herein is typically present in fromabout 50 to about 99 weight percent of the pharmaceutical composition ordosage form.

Examples of disintegrants that can be used in pharmaceuticalcompositions provided herein include, but are not limited to, alginicacid, microcrystalline cellulose, croscarmellose sodium, crospovidone,polacrilin potassium, sodium starch glycolate, potato or tapioca starch,pre gelatinized starch, other starches, clays, other algins, othercelluloses, gums, and mixtures thereof.

Examples of lubricants that can be used in pharmaceutical compositionsprovided herein include, but are not limited to, talc, calcium stearate,magnesium stearate, mineral oil, light mineral oil, polyethylene glycol,other glycols, stearic acid, sodium lauryl sulfate, hydrogenatedvegetable oil (e.g., peanut oil, cottonseed oil, sunflower oil, sesameoil, olive oil, corn oil, and soybean oil), zinc stearate, and mixturesthereof.

Glycerin may be used as a humectant or for additional purposes. Ethyloleate may be used as a solvent or for additional purposes. Ethyllaureate and agar may also be used as excipients.

Additional excipients that may be used in the pharmaceuticalcompositions provided herein include lactose monohydrate; HPMC2910/Hypromellose 6 cP; titanium dioxide; macrogel/PEG3350; triacetin;hydroxyethyl cellulose; copovidone; hydroxypropyl cellulose; HPMC2910/Hypromellose.

In some embodiments of the present invention, a binder, diluents,disintegrant or lubricant is present in the pharmaceutical compositionsprovided herein from about 3 to about 95, from about 3 to about 15, fromabout 15 to about 25, from about 25 to about 45, from about 45 to about60, from about 60 to about 80, or from about 80 to about 95 weightpercent of the pharmaceutical composition or dosage form.

In some embodiments of the present invention, the pharmaceuticalcomposition includes one JAK inhibitor. In some embodiments of thepresent invention, the pharmaceutical composition includes a pluralityof different JAK inhibitors. In some embodiments of the presentinvention, the pharmaceutical composition includes a therapeutic agentthat is not a JAK inhibitor.

In some embodiments of the present invention, the JAK inhibitor istofacitinib or a pharmaceutically acceptable salt thereof. In apreferred embodiment of the present invention, the JAK inhibitor istofacitinib citrate.

In some embodiments of the present invention, tofacitinib citrate ispresent in the pharmaceutical compositions from about 1 to about 10,from about 10 to about 20, from about 20 to about 40, from about 40 toabout 60, or from about 60 to about 90 weight percent of thepharmaceutical compositions.

The pharmaceutical compositions of the present invention can be preparedby any of the methods of pharmacy generally known in the art. Ingeneral, pharmaceutical compositions and dosage forms are prepared byuniformly and intimately admixing the active pharmaceutical ingredientswith liquid carriers, finely divided solid carriers, or both, and thenshaping the product into the desired presentation if necessary.

A pharmaceutical composition in accordance with the invention may beprepared, packaged, and/or sold in bulk, as a single dosage unit, and/oras a plurality of single dosage units.

Dosage Forms

According to the present invention, the pharmaceutical compositionsdisclosed herein may be provided in any of the dosage forms commonlyknown in the art. The dosage forms contemplated by the present inventioncan therefore take the form of tablets, capsules, pills, solutions,suspensions, emulsion, powders and the like. Such dosage forms can beprepared by any of the methods of pharmacy generally known in the art.See for example Remington: The Science and Practice of Pharmacy, 21stEdition (Lippincott, Williams & Wilkins, Baltimore, Md., 2006). Becauseof the ease of administration, tablets and capsules for oraladministration are preferred. If desired, tablets can be coated bystandard aqueous or nonaqueous techniques.

In general, dosage forms are prepared by uniformly and intimatelyadmixing the active pharmaceutical ingredients with liquid carriers,finely divided solid carriers, or both, and then shaping the resultingpharmaceutical composition into the desired presentation if necessary.For example, a tablet can be prepared by compression or molding.

In some embodiments of the present invention, the dosage units areprovided in an immediate release dosage form. In other embodiments ofthe present invention, the dosage units are provided in an extendedand/or controlled release dosage form.

An immediate release dosage unit is a dosage unit containing an activepharmaceutical ingredient the release of which is not extended orcontrolled. Typically, these dosage units release their activepharmaceutical ingredient relatively quickly once the dosage unit hasbeen administered. By contrast, extended and controlled release dosageunits release their active pharmaceutical ingredient over an extendedperiod of time and at certain physiological conditions, respectively.Controlled release of an active pharmaceutical ingredient can bestimulated by various conditions including, but not limited to, pH,temperature, enzymes, water, or other physiological conditions oragents.

The manufacture of immediate release dosage forms and extended and/orcontrolled release dosage forms is widely known in the art, and a personhaving ordinary skill in the art would know how to apply this generalknowledge to the manufacture of such dosage forms including JAKinhibitors, for example tofacitinib citrate. Exemplary extended and/orcontrolled release dosage forms are disclosed for example in U.S. Pat.Nos. 9,669,022 and 9,629,837, which are hereby incorporated by referencein their entirety.

Various approaches are known in the art to prepare extended releasedosage forms. For example, extended release may be achieved by embeddingthe active pharmaceutical ingredient in an extended release polymer.Non-limiting examples of such polymers are disclosed in U.S. Pat. No.9,629,837, which is hereby incorporated by reference in its entirety.

Various approaches are also known in the art to prepare controlledrelease dosage forms. For example, controlled release may be achieved byproviding dosage forms such as pellets, tablets and capsules with acontrolled release coating that breaks down under certain conditionsover time and then, once disintegrated, allows for the release of theunderlying active pharmaceutical ingredient from the dosage unit.Controlled release may also be achieved based on the use of a controlledrelease matrix in which the active pharmaceutical ingredient isembedded.

Non-limiting examples of suitable materials for controlled (for examplebased on pH) release coatings according to the invention includeshellac, cellulose acetate phthalate (CAP), polyvinyl acetate phthalate(PVAP), hydroxypropyl methylcellulose phthalate, and methacrylic acidester copolymers, zein, and the like. See U.S. Pat. No. 9,669,022, whichis hereby incorporated by reference in its entirety.

Non-limiting examples of suitable controlled-release materials which maybe included in a controlled-release matrix according to the inventioninclude: hydrophilic and/or hydrophobic materials, such as gums,cellulose ethers, acrylic resins, protein derived materials, waxes,shellac, and oils such as hydrogenated castor oil, hydrogenatedvegetable oil. However, any pharmaceutically acceptable hydrophobic orhydrophilic controlled-release material which is capable of impartingcontrolled-release of the JAK inhibitors may be used in accordance withthe present invention. Exemplary controlled-release polymers includealkylcelluloses such as ethylcellulose, acrylic and methacrylic acidpolymers and copolymers, and cellulose ethers, especiallyhydroxyalkylcelluloses (especially hydroxypropylmethylcellulose) andcarboxyalkylcelluloses. Examplary acrylic and methacrylic acid polymersand copolymers include methyl methacrylate, methyl methacrylatecopolymers, ethoxyethyl methacrylates, cynaoethyl methacrylate,aminoalkyl methacrylate copolymer, poly(acrylic acid), poly(methacrylicacid), methacrylic acid alkylamine copolymer, poly(methyl methacrylate),poly(methacrylic acid)(anhydride), polymethacrylate, polyacrylamide,poly(methacrylic acid anhydride), and glycidyl methacrylate copolymers.

Specific examples of techniques and pharmaceutically acceptableexcipients that may be used to formulate oral extended and/or controlledrelease dosage forms are also described in the Handbook of SustainedRelease Dosage Form, LAP Lambert Acad. Publ., 2011, and the Handbook ofPharmaceutical Controlled Release Technology, Marcel Dekker Inc, 2000,which are hereby incorporated by reference in their entireties.

Many controlled release dosage units are designed to initially releasean amount of active pharmaceutical ingredient that promptly produces thedesired therapeutic effect, and to gradually and continually release theremaining amount of active pharmaceutical ingredient to maintain thislevel of therapeutic effect over an extended period of time. Thus,strictly speaking, this type of dosage unit is a combination of animmediate release unit and an extended release unit. These and othertypes of combinations of an immediate release unit and an extendedrelease unit are also within the scope of the present invention.

In some embodiments of the present invention, the dosage unit is animmediate-release tablet including the following excipients:microcrystalline cellulose, lactose monohydrate, croscarmellose sodium,magnesium stearate, HPMC 2910/Hypromellose 6 cP, titanium dioxide,macrogol/PEG3350, and triacetin.

In some embodiments of the present invention, the dosage unit is anextended release tablet including the following excipients: sorbitol,hydroxyethyl cellulose, copovidone, magnesium stearate, celluloseacetate, hydroxypropyl cellulose, HPMC 2910/Hypromellose, titaniumdioxide, triacetin, and red iron oxide. Printing ink contains shellacglaze, ammonium hydroxide, propylene glycol, and ferrosoferricoxide/black iron oxide.

In some embodiments of the present invention, microcrystalline celluloseis present in the dosage unit (e.g., tablet) provided herein in anamount of from about 100 to about 400 mg. In a preferred embodiment,microcrystalline cellulose is present in the dosage unit (e.g., tablet)provided herein in an amount of about 123 or about 315 mg.

In some embodiments of the present invention, lactose monohydrate ispresent in the dosage unit (e.g., tablet) provided herein in an amountof from about 50 to about 170 mg. In a preferred embodiment, lactosemonohydrate is present in the dosage unit (e.g., tablet) provided hereinin an amount of about 61 or about 157 mg.

In some embodiments of the present invention, croscarmellose sodium ispresent in the dosage unit (e.g., tablet) provided herein in an amountof from about 5 to about 17 mg. In a preferred embodiment,croscarmellose sodium is present in the dosage unit (e.g., tablet)provided herein in an amount of about 6 or about 15 mg.

In some embodiments of the present invention, magnesium stearate ispresent in the dosage unit (e.g., tablet) provided herein in an amountof from about 1.8 to about 5.5 mg. In a preferred embodiment, magnesiumstearate is present in the dosage unit (e.g., tablet) provided herein inan amount of about 2 or about 5 mg.

In some embodiments of the present invention, sorbitol is present in thedosage unit (e.g., tablet) provided herein in an amount of from about140 to about 160 mg. In a preferred embodiment, sorbitol is present inthe dosage unit (e.g., tablet) provided herein in an amount of about 152mg.

In some embodiments of the present invention, hydroxyethyl cellulose ispresent in the dosage unit (e.g., tablet) provided herein in an amountof from about 14 to about 18 mg. In a preferred embodiment, hydroxyethylcellulose is present in the dosage unit (e.g., tablet) provided hereinin an amount of about 16 mg.

In some embodiments of the present invention, copovidone is present inthe dosage unit (e.g., tablet) provided herein in an amount of fromabout 11 to about 13 mg. In a preferred embodiment, copovidone ispresent in the dosage unit (e.g., tablet) provided herein in an amountof about 12 mg.

In some embodiments of the present invention, magnesium stearate ispresent in the dosage unit (e.g., tablet) provided herein in an amountof from about 1.8 to about 2.2 mg. In a preferred embodiment, magnesiumstearate is present in the dosage unit (e.g., tablet) provided herein inan amount of about 2 mg.

In some embodiments of the present invention, cellulose acetate ispresent in the dosage unit (e.g., tablet) provided herein in an amountof from about 8.2 to about 8.6 mg. In a preferred embodiment, celluloseacetate is present in the dosage unit (e.g., tablet) provided herein inan amount of about 8.4 mg.

In some embodiments of the present invention, hydroxypropyl cellulose ispresent in the dosage unit (e.g., tablet) provided herein in an amountof from about 5.4 to about 5.8 mg. In a preferred embodiment,hydroxypropyl cellulose is present in the dosage unit (e.g., tablet)provided herein in an amount of about 5.6 mg.

In some embodiments of the present invention, the dosage unit includesone JAK inhibitor. In some embodiments of the present invention, thedosage unit includes a plurality of JAK inhibitors. In some embodimentsof the present invention, the dosage unit includes a therapeutic agentthat is not a JAK inhibitor.

In some embodiments of the present invention, the JAK inhibitor istofacitinib or a pharmaceutically acceptable salt thereof. In apreferred embodiment of the present invention, the JAK inhibitor istofacitinib citrate.

In some embodiments of the present invention, tofacitinib citrate ispresent in the dosage units provided herein in an amount from about 1 toabout 2 mg per dosage unit, from about 2 to about 5 mg per dosage unit,from about 5 to about 10 mg per dosage unit, from about 10 to 15 mg perdosage unit, from about 15 to 25 mg per dosage unit, or from about 25 to50 mg per dosage unit, (weights are calculated based on the weight oftofacitinib free base).

In a preferred embodiment of the present invention, tofacitinib citrateis present in the dosage units provided herein in an amount of about 8mg (equivalent to about 5 mg tofacitinib free base) per dosage unit,wherein the dosage unit is an immediate-release film-coated tabletcontaining the following excipients: microcrystalline cellulose, lactosemonohydrate, croscarmellose sodium, magnesium stearate, HPMC2910/Hypromellose 6 cP, titanium dioxide, macrogol/PEG3350, andtriacetin. In an even more preferred embodiment of the presentinvention, tofacitinib citrate is present in the dosage units providedherein in an amount of 8 mg (equivalent to 5 mg tofacitinib free base).

In a preferred embodiment of the present invention, tofacitinib citrateis present in the dosage units provided herein in an amount of about17.77 mg (equivalent to about 11 mg tofacitinib free base) per dosageunit, wherein the dosage unit is an extended release film-coated tabletcontaining the following excipients: sorbitol, hydroxyethyl cellulose,copovidone, magnesium stearate, cellulose acetate, hydroxypropylcellulose, HPMC 2910/Hypromellose, titanium dioxide, triacetin, and rediron oxide. In an even more preferred embodiment of the presentinvention, tofacitinib citrate is present in the dosage units providedherein in an amount of 17.77 mg (equivalent to 11 mg tofacitinib freebase).

Concentrations of active pharmaceutical ingredients (e.g., tofacitinib)and excipients may be measured in accordance with methods and techniquesthat are standard in the pharmaceutical art and therefore not furtherdetailed herein.

Relative amounts of active pharmaceutical ingredient, excipient, and/orany additional ingredients in a pharmaceutical composition and dosageunit in accordance with the invention may vary, depending upon theidentity, size, and/or condition of the subject treated and/or dependingupon the route by which the composition is to be administered. By way ofexample, the composition may comprise between 0.1% and 100% (w/w) activepharmaceutical ingredient.

Also within the scope of the present invention are pharmaceuticalcompositions and dosage forms that include a Janus kinase inhibitor andone or more additional therapeutic agents, which may or may not be adifferent Janus kinase inhibitor. In some embodiments of the presentinvention, the additional therapeutic agent is a an agent commonly usedfor treatment of IDDM.

Routes of Administration and Dosing Regimen

JAK inhibitors, or a pharmaceutically acceptable salts or estersthereof, can be administered by any convenient route commonly known inthe art. Methods of administration include, but are not limited to,oral, parenteral, intradermal, intramuscular, intraperitoneal,intravenous, subcutaneous, intranasal, epidural, sublingual,intracerebral, intravaginal, transdermal, transmucosal, rectal, ortopical administration, or administration by inhalation. The mode ofadministration is left to the discretion of the practitioner. In mostinstances, administration will result in the release of a compound intothe bloodstream.

In a preferred embodiment of the present invention, the JAK inhibitor isadministered orally.

Suitable dosages of JAK inhibitors (or pharmaceutically acceptable saltsor esters thereof) for administration within the scope of the presentinvention include, but are not limited to, JAK inhibitor dosages (ordosages of pharmaceutically acceptable salts or esters thereof) ofbetween about 1 mg and about 10 mg administered to the subject once ortwice daily. In some embodiments of the present invention, suitabledosages include JAK inhibitor dosages (or dosages of pharmaceuticallyacceptable salts or esters thereof) of between about 5 mg and about 8 mgadministered to the subject once or twice daily.

In some embodiments of the present invention, suitable dosages includeJAK inhibitor dosages (or dosages of pharmaceutically acceptable saltsor esters thereof) of between about 10 mg and about 17 mg administeredto the subject once or twice daily. In some embodiments of the presentinvention, suitable dosages include JAK inhibitor dosages (or dosages ofpharmaceutically acceptable salts or esters thereof) of between about 17mg and about 25 mg administered to the subject once or twice daily. Insome embodiments of the present invention, suitable dosages include JAKinhibitor dosages (or dosages of pharmaceutically acceptable salts oresters thereof) of between about 25 mg and about 50 mg administered tothe subject once or twice daily.

Also contemplated within the scope of the present invention are otherdosing regimen, non-limiting examples of which are thrice-daily andfour-times daily administration of a JAK inhibitor, weekly, biweekly andthrice-weekly administration of a JAK inhibitor, and monthly, bimonthlyand thrice-monthly administration of a JAK inhibitor.

In a preferred embodiment of the present invention, an immediate-releasetablet containing tofacitinib citrate in an amount of 5 mg (calculatedbased on the weight of tofacitinib free base) is administered twicedaily, or an extended-release tablet containing tofacitinib citrate inan amount of 11 mg (calculated based on the weight of tofacitinib freebase) is administered once daily.

In a preferred embodiment of the present invention, twoimmediate-release tablets each containing tofacitinib citrate in anamount of 5 mg (calculated based on the weight of tofacitinib free base)are administered twice daily.

In some embodiments of the present invention, the commercially availabletofacitinib in accordance with the present invention is administered inaccordance with the dosage forms approved by the Food and DrugAdministration (FDA) for this type of product.

Intravenous Immunoglobulin (IVIG)

Intravenous immunoglobulin (WIG) is a mixture of antibodies(immunoglobulins) combined from a variety of donors, and is used as areplacement therapy in immune-deficient individuals. Less intuitively,IVIG can also be used to suppress the pathological immune responses thatoccur in patients with autoimmunity. See Schwab & Nimmerjahn, NatureReviews Immunology 13:176-189 (2013); see also Heiner, Review ofInfectious Diseases 8:S391-395.

Intravenous immunoglobulin is commercially available from numeroussources generally known in the art. For example Grifols TherapeuticsInc., NC, USA, markets the GAMUNEX®-C liquid 10% immune globulin productfor injection in humans that has been approved by the FDA for primaryhumoral immunodeficiency (PI) in patients 2 years of age and older,idiopathic thrombocytopenic purpura (ITP), and chronic inflammatorydemyelinating polyneuropathy (CIDP).

The GAMUNEX®-C product is a sterile solution for injection supplied in 1g protein (10 mL), 2.5 protein g (25 mL), 5 g protein (50 mL), 10 gprotein (100 mL), 20 g protein (200 mL), or 40 g protein (400 mL) singleuse bottles. GAMUINEX-C® consists of 9%-11% protein in 0.16-0.24 Mglycine.

The GAMUNEX®-C product contains trace levels of fragments, IgA (average0.046 mg/mL), and IgM. The distribution of IgG subclasses is similar tothat found in normal serum. The main component of the GAMUNEX®-C productis IgG (≥98%) with a sub-class distribution of IgG1, IgG2, IgG3 and IgG4of approximately 62.8%, 29.7%, 4.8% and 2.7%, respectively.

The GAMUNEX®-C product is made from large pools of human plasma by acombination of cold ethanol fractionation, caprylate precipitation andfiltration, and anion-exchange chromatography. Isotonicity is achievedby the addition of glycine. The GAMUNEX®-C product is incubated in thefinal container (at the low pH of 4.0-4.3). The product is intended forintravenous administration and may be administered subcutaneously in thetreatment of PI.

The GAMUINEX®-C product is indicated for intravenous or subcutaneousadministration. For intravenous administration, the dose of GAMUNEX®-Cfor patients with PI is 300 mg/kg to 600 mg/kg body weight (3 mL/kg to 6mL/kg) administered every 3 to 4 weeks. The dosage may be adjusted overtime to achieve the desired trough levels and clinical responses. Therecommended initial infusion rate is 1 mg/kg/min (0.01 mL/kg/min). Ifthe infusion is well-tolerated, the rate may be gradually increased to amaximum of 8 mg/kg/min (0.08 mL/kg/min). For subcutaneous administrationto patients with PI, the dose of the GAMUNEX®-C product is determinedand possibly adjusted over time based on prior administration of otherIVIG and the patient's clinical response, in accordance withprotocols/methods commonly known in the art.

The rate of administration of the GAMUNEX®-C product for intravenousadministration to patients with PI is 1 mg/kg/min for the first 30minutes, which is then increased up to a maximum of 8 mg/kg/min iftolerated.

See Prescribing Information for the GAMUNEX®-C Drug Product (revised2016).

Pharmaceutical Compositions, Dosage Forms, Routes of Administration andDosing Regimen

In a preferred embodiment, the intravenous immunoglobulin isadministered to a subject in the form of a sterile solution forinjection supplied in 1 g immunoglobulin (10 mL), 2.5 g immunoglobulin(25 mL), 5 g immunoglobulin (50 mL), 10 g immunoglobulin (100 mL), 20 gimmunoglobulin (200 mL), or 40 g immunoglobulin (400 mL) single usebottles, wherein the immunoglobulin is present at a concentration of9%-11% w/v in 0.16-0.24 M glycine.

The pharmaceutical compositions, dosage forms and routes ofadministration of intravenous immunoglobulin contemplated as part of thepresent invention are not limited to pharmaceutical compositions thatare particular liquid injectables for intravenous or subcutaneousadministration, but include all types of pharmaceutical compositions,dosage forms and routes of administration commonly known and used in theart for immunoglubulins, as further described in connection with thedisclosure of pharmaceutical compositions, dosage forms and routes ofadministration of therapeutic agents that destroy B lymphocytes, whichis also applicable to intravenous immunoglobulin.

In some embodiments of the present invention, intravenous immunoglobulin(IVIG) is administered by injection. In some embodiments of the presentinvention, intravenous immunoglobulin (IVIG) is administered byinfusion.

In some embodiments of the present invention, the dose of intravenousimmunoglobulin for patients with IDDM is about 0.01, about 0.1, about 1,about 2, about, 3, about, 4, about 5, about 10, about 50 or about 100mg/kg body weight of the patient.

In some embodiments of the present invention, a dose of intravenousimmunoglobulin is administered once daily; or once every 2, 3, 4, 5, 6or 7 days; or once every week; or once every 2, 3, 4, 5, 6, 7, 8, 9 or10 weeks, for a total 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 doses.

In some embodiments of the present invention, a dose of intravenousimmunoglobulin is administered at the beginning of the dosing regimen onseveral consecutive days (e.g., 2, 3, 4, 5, 6, 7, 8, 9 or 10 days), andthen administered every 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 weeks. In apreferred embodiment of the present invention, a dose of intravenousimmunoglobulin is administered on each of days 1, 2 and 3 at thebeginning of the dosing regimen. In a preferred embodiment of thepresent invention, doses of intravenous immunoglobulin are administeredevery 3 weeks after the administration of doses of intravenousimmunoglobulin on 3 consecutive days at the beginning of the dosingregimen. In a preferred embodiment of the present invention, these firstthree doses are 1 or 2 mg intravenous immunoglobulin.

In some embodiments of the present invention, the intravenousimmunoglobulin in accordance with the present invention is administeredin accordance with the dosage forms and dosing regimens approved by theFDA for this type of product.

Also within the scope of the present invention are pharmaceuticalcompositions and dosage forms that include intravenous immunoglobulinand one or more additional therapeutic agents.

Therapeutic Agent that Destroys B Lymphocytes

The present invention provides a method of treating insulin-dependentdiabetes mellitus in a subject including administering to the subject atherapeutically effective amount of a Janus kinase inhibitor, or apharmaceutically acceptable salt or ester thereof, therapeuticallyeffective amount of intravenous immunoglobulin, or therapeuticallyeffective amount of a therapeutic agent that destroys B lymphocytes, orcombinations thereof.

In some embodiments of the present invention, the therapeutic agent thatdestroys B lymphocytes is an anti-CD20 antibody agent. In a preferredembodiment, the anti-CD20 antibody agent is the antibody rituximab, orantibody fragments thereof.

B-lymphocyte antigen CD20 corresponds to a phosphoprotein located on thesurface of B-cells that has been reported to facilitate optimal B-cellimmune responses. CD20 is targeted by a number of therapeutic antibodiesthat have been approved by the FDA for the treatment of a variety ofconditions.

Rituximab is currently being marketed by Biogen Inc. and Genentech USA,Inc. under the tradename Rituxan®. Rituximab is a monoclonal antibodythat binds to the CD20 antigen located on the surface of pre-B andmature B-lymphocytes. Upon binding to CD20, rituximab mediates B-celllysis, possibly via complement dependent cytotoxicity (CDC) or antibodydependent cell mediated cytotoxicity (ADCC), resulting in destruction ofB lymphocytes. See Prescribing Information for the Rituxan® RituximabDrug Product (2016).

Rituximab is a murine/human chimeric monoclonal IgG1 kappa antibodydirected to the CD20 antigen. Rituximab has an approximate molecularweight of 145 kD and a binding affinity for the CD20 antigen ofapproximately 8.0 nM. See Prescribing Information for the Rituxan®Rituximab Drug Product (2016).

The isolation, screening, and characterization of rituximab is taught byU.S. Pat. Nos. 5,736,137; 5,776,456 and 5,843,439, which are herebyincorporated by reference in their entireties.

Rituximab is produced in Chinese hamster ovary cells and provided as asterile, clear, colorless, preservative-free liquid concentrate forintravenous administration. Rituximab is supplied at a concentration of10 mg/mL in either 100 mg/10 mL or 500 mg/50 mL single-use vials. Therituximab is formulated in polysorbate 80 (0.7 mg/mL), sodium chloride(9 mg/mL), sodium citrate dihydrate (7.35 mg/mL), and water forinjection. The pH is 6.5. Before use, an appropriate amount of theaforesaid rituximab concentrate is diluted to a final concentration of 1mg/mL to 4 mg/mL in an infusion bag containing either 0.9% SodiumChloride, USP, or 5% Dextrose in Water, USP. See Prescribing Informationfor the Rituxan® Rituximab Drug Product (2016).

B cells are believed to play a role in the pathogenesis of rheumatoidarthritis (RA) and associated chronic synovitis. In this setting, Bcells may be acting at multiple sites in the autoimmune/inflammatoryprocess, including through production of rheumatoid factor (RF) andother autoantibodies, antigen presentation, T-cell activation, and/orproinflammatory cytokine production. See Prescribing Information for theRituxan® Rituximab Drug Product (2016).

Rituximab has been approved for the treatment of Non-Hodgkin's Lymphoma(NHL). Rituximab has also been approved for the treatment of ChronicLymphocytic Leukemia (CLL), Rheumatoid Arthritis (RA), andGranulomatosis with Polyangiitis (GPA) (Wegener's Granulomatosis) andMicroscopic Polyangiitis (MPA).

For the treatment of Non-Hodgkin's Lymphoma (NHL), the recommended doseof rituximab is 375 mg/m² as an intravenous infusion.

For the treatment of Chronic Lymphocytic Leukemia (CLL), the recommendeddose is 375 mg/m² the day prior to the initiation of FC chemotherapy,then 500 mg/m² on Day 1 of cycles 2-6 (every 28 days).

For the treatment of NHL as a component of the Zevalin® drug product,rituximab is infused at 250 mg/m² within 4 hours prior to theadministration of Indium-111-(In-111-) Zevalin and within 4 hours priorto the administration of Yttrium-90-(Y-90-) Zevalin.

For the treatment of Rheumatoid Arthritis (RA), rituximab isadministered as two-1000 mg intravenous infusions separated by 2 weeks.Glucocorticoids administered as methylprednisolone 100 mg intravenous orits equivalent 30 minutes prior to each infusion are recommended toreduce the incidence and severity of infusion reactions. Subsequentcourses are administered every 24 weeks or based on clinical evaluation,but not sooner than every 16 weeks. Rituxan is administered incombination with methotrexate.

For the treatment of Granulomatosis with Polyangiitis (GPA) (Wegener'sGranulomatosis) and Microscopic Polyangiitis (MPA), rituximab isadministered as a 375 mg/m² intravenous infusion once weekly for 4weeks. Glucocorticoids administered as methylprednisolone 1000 mgintravenously per day for 1 to 3 days followed by oral prednisone 1mg/kg/day (not to exceed 80 mg/day and tapered per clinical need) arerecommended to treat severe vasculitis symptoms. This regimen beginswithin 14 days prior to or with the initiation of rituximab treatmentand may continue during and after the 4 week course of rituximabtreatment. See Prescribing Information for the Rituxan® Rituximab DrugProduct (2016).

Non-limiting examples of other anti-CD20 therapeutic antibody agentsthat have been approved by the FDA for the treatment of a variety ofconditions, or are in preclinical or clinical trials, include thefollowing:

Obinutuzumab, which is a humanized anti-CD20 monoclonal antibody of theIgG1 subclass currently being marketed by Genentech, Inc. under thetradename Gazyva®; ofatumumab which is a human anti-CD20 monoclonalantibody of the IgG1 subclass currently being marketed by NovartisPharmaceuticals Corporation under the tradename Arzerra®; ibritumomabtiuxetan, which is a murine anti-CD20 monoclonal antibody of the IgG1subclass conjugated with the linker-chelator tiuxetan[N-[2-bis(carboxymethyl)amino]-3-(p-isothiocyanatophenyl)-propyl]-[N-[2-bis(carboxymethyl)amino]-2-(methyl)-ethyl]glycinecurrently being marketed by Spectrum Pharmaceuticals, Inc., under thetradename Zevalin®; ocrelizumab, which is a humanized anti-CD20monoclonal antibody of the IgG1 subclass currently being marketed byGenentech, Inc., under the tradename Ocrevus; tositumomab, which is amurine anti-CD20 monoclonal antibody (see Srinivasan & Mukherji, AJNR.American Journal of Neuroradiology 32:637-638 (2011)); ocaratuzumab,which is a humanized anti-CD20 monoclonal antibody (see Cheney et al.,Monoclonal Antibodies 6:748-754 (2014)); TRU-015, which is a fusionprotein derived from an anti-CD20 antibody (see Rubbert-Roth, CurrentOpinion in Molecular Therapeutics 12:115-123 (2010)); and veltuzumab,which is a humanized anti-CD20 monoclonal antibody (see Cang et al.,Journal of Hematology & Oncology 5:64 (2012)).

Antibody Agents, Antibody Fragments & Antibody Conjugates

In some embodiments of the present invention, the therapeutic agent thatdestroys B lymphocytes is an anti-CD20 antibody agent. In a preferredembodiment, the anti-CD20 antibody agent is the antibody rituximab.

The term “anti-CD20 antibody agent” refers to an antibody agent thatspecifically binds to the CD20 antigen. Consistent with the definitionof the term “antibody agent” elsewhere herein, an anti-CD20 antibodyagent includes, but is not limited to, the following formats, all ofwhich bind to the CD20 antigen: murine antibodies, chimeric antibodies(e.g., human/mouse), primatized antibodies, humanized antibodies, humanantibodies, bi-specific antibodies, conjugated antibodies, single chainantibodies, and antibody fragments.

All of the antibody agent formats disclosed herein are widely used inthe art and known by the person having ordinary skill in the art.Technologies for generating such formats (e.g., monoclonal antibodiesand/or polyclonal antibodies) are well known in the art. See, e.g.,Antibodies: A Laboratory Manual, Second edition, Edited by Edward A.Greenfield, Cold Spring Harbor Laboratory Press (2014).

It will be appreciated that a wide range of animal species can be usedfor the production of antisera, including rabbit, mouse, rat, hamster,guinea pig or goat. The animal species may be chosen based on the easeof manipulation, costs or the desired amount of sera, as would be knownto one of skill in the art. It will be appreciated that antibody agentscan also be produced transgenically through the generation of a mammalor plant that is transgenic for the immunoglobulin heavy and light chainsequences of interest. In connection with the transgenic production inmammals, antibodies can be produced in, and recovered from, the milk ofgoats, cows, or other mammals. See, e.g., U.S. Pat. No. 5,827,690, whichis incorporated herein by reference in its entirety.

Antibody agents provided herein may be produced, for example, byutilizing a host cell system engineered to express a nucleic acidencoding an inventive antibody agent. Alternatively or additionally,antibody agents provided herein may be partially or fully prepared bychemical synthesis (e.g., using an automated peptide synthesizer).

Technologies for making and using polyclonal and monoclonal antibodiesare described, e.g., in Harlow et al., Using Antibodies: A LaboratoryManual: Portable Protocol I. Cold Spring Harbor Laboratory (Dec. 1,1998). Technologies for making modified antibody agents, such as,antibodies and antibody fragments (e.g., chimeric antibodies, reshapedantibodies, humanized antibodies, or fragments thereof, e.g., Fab′, Fab,F(ab′)₂ fragments); or biosynthetic antibodies (e.g., single chainantibodies, single domain antibodies (DABs), Fv, single chain Fv (scFv),and the like), are known in the art and can be found, e.g., in Zola,Monoclonal Antibodies: Preparation and Use of Monoclonal Antibodies andEngineered Antibody Derivatives, Springer Verlag (Dec. 15, 2000; 1stedition).

Exemplary sources for antibody agent preparations suitable for theinvention include, but are not limited to, conditioned culture mediumderived from culturing a recombinant cell line that expresses a proteinof interest; extracts of, e.g., bacteria, fungal cells, insect cells,transgenic plants or plant cells, transgenic animals or animal cellsexpressing a protein of interest; serum or ascites fluid of animals; andhybridoma or myeloma supernatants. Suitable bacterial cells include, butare not limited to, Escherichia coli cells. Examples of suitable E. colistrains include: HBIOI, DH5a, GM2929, JM109, KW251, NM538, NM539, andany other E. coli strain that fails to cleave foreign DNA. Suitablefungal host cells that can be used include, but are not limited to,Saccharomyces cerevisiae, Pichia pastoris and Aspergillus cells.Suitable insect cells include, but are not limited to, S2 Schneidercells, D. Mel-2 cells, SF9, SF21, High-5™ Mimic™-SF9, MGI and KCl cells.Suitable exemplary recombinant eukaryotic cell lines include, but arenot limited to, BALB/c mouse myeloma line, human retinoblasts (PER.C6),monkey kidney cells, human embryonic kidney line (293), baby hamsterkidney cells (BHK), Chinese hamster ovary cells (CHO), mouse sertolicells, African green monkey kidney cells (VERO-76), human cervicalcarcinoma cells (He La), canine kidney cells, buffalo rat liver cells,human lung cells, human liver cells, mouse mammary tumor cells, TRIcells, MRC 5 cells, FS4 cells, and human hepatoma line (Hep G2). In apreferred embodiment of the present invention, rituximab is produced inChinese hamster ovary cells.

Antibody agents of interest can be expressed using any appropriatevector. A variety of vectors (e.g., viral vectors) is known in the art.Cells into which such vectors can been introduced (or progeny of suchcells) can be cultured according to general knowledge in the art (e.g.,by using continuous or fed-batch culture systems). In some embodimentsof the present invention, cells may be genetically engineered;technologies for genetically engineering cells to express engineeredpolypeptides (e.g., antibody agent polypeptides, as described herein)are well known in the art. See e.g. Ausubel et al., eds. (1990), CurrentProtocols in Molecular Biology (Wiley, New York).

In some embodiments of the present invention, the antibody agentsprovided herein may be purified, if desired, using filtration,centrifugation and/or a variety of chromatographic technologies such asHPLC or affinity chromatography. In some embodiments of the presentinvention, fragments of provided antibody agents are obtained by methodswhich include digestion with enzymes, such as pepsin or papain, and/orby cleavage of disulfide bonds by chemical reduction.

Based on one or more known antibodies, a person having ordinary skill inthe art would know how to prepare corresponding antibody agents of theaforesaid formats such that they have the same binding activities as theknown antibodies. See, e.g., Benny K. C. Lo (ed.), AntibodyEngineering—Methods and Protocols, Humana Press 2004, and referencescited therein.

Single-chain Fvs (scFvs) are widely known and used in the art. Asingle-chain Fv is a fusion protein of the variable regions of the heavy(VH) and light chains (VL) of immunoglobulins, often connected by ashort linker peptide. See, e.g., Benny K. C. Lo (ed.), AntibodyEngineering—Methods and Protocols, Humana Press 2004, and referencescited therein. In some embodiments of the present invention, a scFvpolypeptide is conjugated to a therapeutic agent or detection agent.

Bispecific antibodies are widely known and used in the art. Bispecificantibodies are artificial proteins that include fragments from twodifferent antibodies and consequently bind to two different types ofantigens. In some embodiments of the present invention, bispecificantibodies include two different immunoglobulin heavy chains and twodifferent immunoglobulin light chains.

In some embodiments of the present invention, the anti-CD20 antibodyagent comprises all CDRs of rituximab. A person having ordinary skill inthe art would know how to identify the CDRs of rituximab and use themfor the many antibody formats disclosed herein based on the disclosuresin this specification and common knowledge in the art.

In some embodiments of the present invention, an antibody agent asdescribed herein is associated with a payload entity and thereby forms aconjugate. In some embodiments of the present invention, a payloadentity is or comprises a therapeutic agent. In some embodiments of thepresent invention, a payload entity is or comprises a detection agent.

Therapeutic agents can be or comprise any class of chemical entityincluding, for example, but not limited to, proteins, carbohydrates,lipids, nucleic acids, small organic molecules, non-biological polymers,metals, ions, radioisotopes, etc. In some embodiments of the presentinvention, the conjugated therapeutic agent is a radioisotope, a drugconjugate, a nanoparticle, an immune-toxin, or any other therapeuticpayload. In some embodiments of the present invention, therapeuticagents for use in accordance with the present invention have one or morepharmacological activities.

Several technologies are generally known in the art for the attachmentor conjugation of an antibody agent to a therapeutic or detection agent.Some attachment technologies involve the use of a metal chelate complexemploying, for example, an organic chelating agent such asdiethylenetriaminepentaacetic acid anhydride (DTPA);ethylenetriaminetetraacetic acid; N-chloro-p-toluenesulfonamide; and/ortetrachloro-3a-6a-diphenylglycouril-3 attached to the antibody. See U.S.Pat. Nos. 4,472,509 and 4,938,948, each of which is incorporated hereinby reference in its entirety. Provided antibody agents may also bereacted with an enzyme in the presence of a coupling agent such asglutaraldehyde or periodate.

It will be appreciated that the antibody agents provided herein may beengineered, produced, and/or purified in such a way as to improvecharacteristics and/or activities of the antibody agents. For example,improved characteristics of provided antibody agents include, but arenot limited to, increased stability, improved binding affinity and/oravidity, increased binding specificity, increased production, decreasedaggregation, decreased nonspecific binding, among others.

Pharmaceutical Compositions & Dosage Forms

The present invention also provides a pharmaceutical compositionincluding a therapeutic agent that destroys B lymphocytes, an antibodyagent, rituximab or an antibody fragment thereof, or other antibodyagent formats as disclosed herein, and a pharmaceutically acceptablecarrier.

The pharmaceutical compositions contemplated as part of the presentinvention are not limited to pharmaceutical compositions that can beadministered to a subject by infusion or injection, but include alltypes of pharmaceutical compositions and dosage forms commonly known andused in the art.

Preferably, the therapeutic agent that destroys B lymphocytes (e.g.,anti-CD20 antibody agent) provided herein is formulated as a sterileliquid pharmaceutical composition suitable for subcutaneous injection orintravenous infusion and/or injection. In some embodiments of thepresent invention, pharmaceutical compositions are provided as powders(e.g., lyophilized and/or sterilized), optionally under vacuum, whichare reconstituted with an aqueous diluent (e.g., water, buffer, saltsolution, etc.) prior to injection. In some embodiments of the presentinvention, pharmaceutical compositions are diluted and/or reconstitutedin water, sodium chloride solution, sodium acetate solution, benzylalcohol solution, phosphate buffered saline, etc. In some embodiments ofthe present invention, powder should be mixed gently with the aqueousdiluent (e.g., not shaken).

In some embodiments of the present invention, provided pharmaceuticalcompositions comprise one or more pharmaceutically acceptableexcipients. In some embodiments of the present invention, pharmaceuticalcompositions comprise one or more preservatives. In some embodiments ofthe present invention, pharmaceutical compositions comprise nopreservative. Excipients as used herein may be or comprise solvents,dispersion media, diluents, or other liquid vehicles, dispersion orsuspension aids, surface active agents, isotonic agents, thickening oremulsifying agents, preservatives, solid binders, lubricants and thelike, as suited to the particular dosage form and administration routedesired. Remington's The Science and Practice of Pharmacy, 21st Edition,A. R. Gennaro, (Lippincott, Williams & Wilkins, Baltimore, Md., 2006)discloses a variety of excipients used in formulating pharmaceuticalcompositions and known techniques for the preparation thereof. Exceptinsofar as any conventional excipient is incompatible with a substanceor its derivatives in the pharmaceutical composition, such as byproducing any undesirable biological effect or otherwise interacting ina deleterious manner with any other component(s) of the pharmaceuticalcomposition, its use is contemplated to be within the scope of thisinvention.

In a preferred embodiment of the present invention, an antibody agent(e.g., rituximab) is provided as a sterile, clear, colorless,preservative-free liquid concentrate for intravenous administration. Inthis preferred embodiment, the antibody agent (e.g., rituximab) issupplied at a concentration of 10 mg/mL in either 100 mg/10 mL or 500mg/50 mL single-use vials, which further contain polysorbate 80 (0.7mg/mL), sodium chloride (9 mg/mL), sodium citrate dihydrate (7.35mg/mL), and water for injection.

In some embodiments of the present invention, an antibody agent (e.g.,rituximab) is provided at a concentration of 1, 2, 3, 4, 5, 6, 7, 8, 9,10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27,28, 29 or 30 mg/mL

In some embodiments of the present invention, an antibody agent (e.g.,rituximab) is provided in a liquid concentrate for intravenousadministration comprising 0.1, 02, 0.3, 0.4, 0.5, 0.7, 0.8, 0.9, 1.0,1.1, 1.2, 1.3, 1.4, or 1.5 mg/mL polysorbate 80; 1, 2, 3, 4, 5, 6, 7, 8,9, 10, 11, 12, 13, 14, or 15 mg/mL sodium chloride; 1, 2, 3, 4, 5, 6, 7,7.35, 8, 9, 10, 11, 12, 13, or 14 mg/mL sodium citrate dihydrate; andwater.

In a preferred embodiment of the present invention, an appropriateamount of the aforesaid concentrate of an antibody agent (e.g.,rituximab) is diluted to a final concentration of 1 mg/mL to 4 mg/mL inan infusion bag containing either 0.9% Sodium Chloride, USP, or 5%Dextrose in Water, USP.

In some embodiments of the present invention, pharmaceuticalcompositions are provided in a form that can be refrigerated and/orfrozen. In some embodiments of the present invention, pharmaceuticalcompositions are provided in a form that cannot be refrigerated and/orfrozen. In some embodiments of the present invention, reconstitutedsolutions and/or liquid dosage forms may be stored for a certain periodof time after reconstitution (e.g., 2 hours, 12 hours, 24 hours, 2 days,5 days, 7 days, 10 days, 2 weeks, a month, two months, or longer).

Liquid dosage forms and/or reconstituted solutions may compriseparticulate matter and/or discoloration prior to administration. In someembodiments of the present invention, a solution should not be used ifdiscolored or cloudy and/or if particulate matter remains afterfiltration.

Pharmaceutical compositions described herein may be prepared by anymethod known or hereafter developed in the art of pharmacology. In someembodiments of the present invention, such preparatory methods includethe step of bringing an active pharmaceutical ingredient intoassociation with one or more excipients and/or one or more otheraccessory ingredients, and then, if necessary and/or desirable, shapingand/or packaging the product into a desired single dosage unit ormultiple dosage units.

A pharmaceutical composition in accordance with the invention may beprepared, packaged, and/or sold in bulk, as a single dosage unit, and/oras a plurality of single dosage units.

Relative amounts of active pharmaceutical ingredient, pharmaceuticallyacceptable excipient, and/or any additional ingredients in apharmaceutical composition in accordance with the invention may vary,depending upon the identity, size, and/or condition of the subjecttreated and/or depending upon the route by which the composition is tobe administered. By way of example, the composition may comprise between0.1% and 100% (w/w) active pharmaceutical ingredient.

Also within the scope of the present invention are pharmaceuticalcompositions and dosage forms that include two or more differenttherapeutic agents that destroy B lymphocytes, or one or moretherapeutic agents that destroy B lymphocytes and one or moretherapeutic agents that are not therapeutic agents that destroy Blymphocytes. In one embodiment of the present invention, thepharmaceutical compositions or dosage form includes one antibody agentwherein a subpopulation of this antibody agent is conjugated with apayload entity, and another subpopulation of this antibody agent isconjugated with a different type of payload entity.

Concentrations of active pharmaceutical ingredients (e.g., rituximab)and excipients may be measured in accordance with methods and techniquesthat are standard in the pharmaceutical art and therefore not furtherdetailed herein. For example, the concentration of rituximab in apharmaceutical composition or dosage form may be measured based onprotein absorbance at 280 nm, or by using on enzyme-linked immunosorbentassay (ELISA). These and other approaches are widely known in the artand thus not further detailed herein.

Routes of Administration and Dosing Regimen

The pharmaceutical compositions and dosage forms of the therapeuticagents and antibody agents disclosed herein may be administered by anymeans commonly used in the art. In some embodiments of the presentinvention, antibody agent includes therapeutic agents that destroy Blymphocytes, for example rituximab or fragments thereof. In someembodiments of the present invention, the pharmaceutical composition anddosage form may be administered subcutaneously or intravenously.

Pharmaceutical compositions of the present invention may be administeredby any appropriate route, as will be appreciated by those skilled in theart. In some embodiments of the present invention, a pharmaceuticalcomposition including an antibody agent of the present invention isadministered by an intravenous (IV), intramuscular (IM), intra-arterial,subcutaneous (SQ), transdermal, interdermal, intradermal, orintraperitoneal (IP) route. In some embodiments of the presentinvention, pharmaceutical compositions including antibody agents of thepresent invention may be administered via portal vein catheter.

In some embodiments of the present invention, the pharmaceuticalcomposition including an antibody agent of the present invention (e.g.,rituximab) is administered by injection. In some embodiments of thepresent invention, the pharmaceutical composition including an antibodyagent of the present invention (e.g., rituximab) is administered byinfusion.

In a preferred embodiment of the present invention, the pharmaceuticalcomposition including an antibody agent of the present invention (e.g.,rituximab) is administered intravenously.

In some embodiments of the present invention, pharmaceuticalcompositions including antibody agents (e.g., rituximab) in accordancewith the invention may be administered at dosage levels sufficient todeliver from about 0.001 mg to about 100 mg, from about 0.01 mg to about50 mg, from about 0.1 mg to about 40 mg, from about 0.5 mg to about 30mg, or from about 1.0 mg to about 10 mg of antibody agent per kg subjectbody weight per day, per week, or per month to obtain the desiredtherapeutic effect.

In some embodiments of the present invention, pharmaceuticalcompositions including antibody agents (e.g., rituximab) in accordancewith the invention may be administered at a dose of 1-50, 50-100,100-150, 150-200, 200-250, 250-300, 300-350, 350-400, 400-450, 450-500,500-550, 550-600, 600-650, 650-700, 700-750, 750-800, 800-850, 850-900,900-950, 950-1000, 1000-1050, 1050-1100, 1100-1150, 1150-1200,1200-1250, 1250-1300, 1300-1350, 1350-1400, 1400-1450, or 1450-1500 mgof antibody agent per m² subject surface area. In preferred embodiments,the dose is 250, 375 or 1000 mg/m² subject surface area.

The desired dose may be delivered once or several times daily, weekly,bi-weekly, thrice weekly, monthly, bi-monthly, thrice-monthly, or at anyother frequency that has therapeutic benefit, as determined by thehealth professional supervising the administration.

In some embodiments of the present invention, the dosing regimenincludes administering the desired dose for a total of 2, 3, 4, 5, 6, 7,8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25,26, 27, 28, 29, or 30 times. In some embodiments of the presentinvention, the doses are administered in one cycle. In some embodimentsof the present invention, the doses are administered in 2, 3, 4, 5, 6,7, 8, 9, or 10 cycles.

In a preferred embodiment, rituximab is administered to a subject at adose of 375 mg/m² once per week for three weeks.

In some embodiments of the present invention, the therapeutic agent thatdestroys B lymphocytes in accordance with the present invention isadministered in accordance with the dosage forms approved by the FDA forthis type of product.

Treatment of IDDM

The present invention provides a method of treating insulin-dependentdiabetes mellitus in a subject including administering to the subject atherapeutically effective amount of a Janus kinase inhibitor, or apharmaceutically acceptable salt or ester thereof, therapeuticallyeffective amount of intravenous immunoglobulin, or therapeuticallyeffective amount of a therapeutic agent that destroys B lymphocytes, orcombinations thereof. In some embodiments of the present invention, theJanus kinase inhibitor, or a pharmaceutically acceptable salt or esterthereof, is a JAK1/3 inhibitor or JAK3 inhibitor. In some embodiments ofthe present invention, the Janus kinase inhibitor, or a pharmaceuticallyacceptable salt or ester thereof, is a JAK1/3 inhibitor. In someembodiments of the present invention, the Janus kinase inhibitor, or apharmaceutically acceptable salt or ester thereof, is tofacitinib. In apreferred embodiment of the present invention, the Janus kinaseinhibitor, or a pharmaceutically acceptable salt thereof, is tofacitinibcitrate. In some embodiments of the present invention, the therapeuticagent that destroys B lymphocytes (B cells) is an anti-CD20 antibodyagent. In a preferred embodiment of the present invention, thetherapeutic agent that destroys B lymphocytes (B cells) is the antibodyrituximab, or fragments thereof.

In some embodiments of the present invention, the subject that istreated is in need of such treatment. A subject in need of treatment mayinclude individuals already having a specified condition or disorder(e.g., IDDM), individuals who are at risk for developing or acquiringthat condition or disorder (e.g., IDDM), and/or individuals in which thecondition or disorder is to be prevented or treated. Treatment thusincludes therapeutic as well as prophylactic/preventative measures.

In accordance with the present invention, the JAK inhibitor, or apharmaceutically acceptable salt or ester thereof, intravenousimmunoglobulin and anti-CD20 antibody agent may be administeredaccording to any therapeutically appropriate route and dosing regimen,including those disclosed elsewhere herein.

In a preferred embodiment of the present invention, the JAK inhibitor,or a pharmaceutically acceptable salt or ester thereof, is administeredorally, and the intravenous immunoglobulin and anti-CD20 antibody agentare administered intravenously by infusion.

In some embodiments of the present invention, the exact dosing regimenmay vary from subject to subject, depending on one or more factors as iswell known in the medical arts. Such factors may include, for example,one or more of the following: the subject's age, body weight, generalhealth, sex, diet and general condition; the severity of the infection;the specific pharmaceutical composition administered and its half-life;the route of administration; the pharmacokinetics and pharmacodynamicsof the active pharmaceutical ingredient; the disorder being treated andthe severity of the disorder; the activity of the specific antibodyagent employed; the duration of the treatment; other activepharmaceutical ingredients used in combination or coincidental with thespecific compound employed and the like. Pharmaceutical compositions maybe formulated such that the dosage unit is equivalent to the dose amountfor ease of administration and uniformity of dosing. It will beunderstood, however, that the total daily, weekly or monthly usage ofthe pharmaceutical compositions and dosage forms of the presentinvention will be decided by the attending physician within the scope ofsound medical judgment.

In a preferred embodiment of the present invention, the dosing regimensand routes of the administration of the JAK inhibitor, orpharmaceutically acceptable salt or ester thereof, intravenousimmunoglobulin and therapeutic agent that destroys B lymphocytes arethose approved by the FDA.

In some embodiments of the present invention, tofacitinib citrate isadministered as an immediate-release tablet including about 8 mg oftofacitinib citrate (corresponding to about 5 mg of tofacitinib freebase) and excipients, such as but not limited to one or more binders, orone or more diluents, or one or more disintegrants, or one or morelubricants, or combinations thereof.

In some embodiments of the present invention, tofacitinib citrate isadministered as an extended release tablet including about 17.77 mg oftofacitinib citrate (corresponding to about 11 mg of tofacitinib freebase) and excipients, such as but not limited to one or more binders, orone or more diluents, or one or more disintegrants, or one or morelubricants, or combinations thereof.

In some embodiments of the present invention, tofacitinib citrate isadministered as an immediate-release tablet including the followingexcipients: microcrystalline cellulose, lactose monohydrate,croscarmellose sodium, magnesium stearate, HPMC 2910/Hypromellose 6 cP,titanium dioxide, macrogol/PEG3350, and triacetin.

In some embodiments of the present invention, tofacitinib citrate isadministered as an extended release tablet including the followingexcipients: sorbitol, hydroxyethyl cellulose, copovidone, magnesiumstearate, cellulose acetate, hydroxypropyl cellulose, HPMC2910/Hypromellose, titanium dioxide, triacetin, and red iron oxide.Printing ink contains shellac glaze, ammonium hydroxide, propyleneglycol, and ferrosoferric oxide/black iron oxide.

In some embodiments of the present invention, tofacitinib citrate isadministered once, twice or thrice daily; once, twice or thrice weekly;or once, twice or thrice monthly; at a dose of 1, 2, 3, 4, 5, 6, 7, 8,9, 10, 11, 12, 13, 14, 15, 16, 17, 17.77, 18, 19, 20, 21, 22, 23, 24,25, 27, 28, 29, or 30 mg per dosage unit administered.

In preferred embodiments, 8 or 16 mg of tofacitinib citrate isadministered to the patient once or twice daily.

In some embodiments of the present invention, the dose of intravenousimmunoglobulin for patients with IDDM is about 0.01, about 0.1, about 1,about 2, about, 3, about, 4, about 5, about 10, about 50 or about 100mg/kg body weight of the patient.

In some embodiments of the present invention, a dose of intravenousimmunoglobulin is administered once daily; or once every 2, 3, 4, 5, 6or 7 days; or once every week; or once every 2, 3, 4, 5, 6, 7, 8, 9 or10 weeks, for a total 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 doses.

In some embodiments of the present invention, a dose of intravenousimmunoglobulin is administered at the beginning of the dosing regimen onseveral consecutive days (e.g., 2, 3, 4, 5, 6, 7, 8, 9 or 10 days), andthen administered every 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 weeks. In apreferred embodiment of the present invention, a dose of intravenousimmunoglobulin is administered on each of days 1, 2 and 3 at thebeginning of the dosing regimen. In a preferred embodiment of thepresent invention, doses of intravenous immunoglobulin are administeredevery 3 weeks after the administration of doses of intravenousimmunoglobulin on 3 consecutive days at the beginning of the dosingregimen. In a preferred embodiment of the present invention, these firstthree doses are 1 or 2 mg intravenous immunoglobulin.

In a preferred embodiment, two immediate-release tablets each comprising8 mg of tofacitinib citrate and the excipients microcrystallinecellulose, lactose monohydrate, croscarmellose sodium, magnesiumstearate, HPMC 2910/Hypromellose 6 cP, titanium dioxide,macrogol/PEG3350, and triacetin are administered to the subject twicedaily, and 1 to 2 mg intravenous immunoglobulin per kg weight of thesubject is administered every 1 to 3 weeks, after an initial loadingdose of 2 mg/Kg of IVIG on the first day followed by doses of 1 mg/KgIVIG on the second and third day.

In some embodiments of the present invention, rituximab is administeredas an infusion at a dose of from 100 to 1000 mg/m² once or several timesdaily, weekly, bi-weekly, thrice weekly, monthly, bi-monthly,thrice-monthly, or at any other frequency that has therapeutic benefit,as determined by the health professional supervising the administration.

In a preferred embodiment, rituximab is administered to a subject at adose of 375 mg/m² once per week for three weeks.

The therapeutically effective amounts of the JAK inhibitor, orpharmaceutically acceptable salt or ester thereof, intravenousimmunoglobulin and therapeutic agent that destroys B lymphocytes aredetermined by the person skilled in the art (e.g., physician) inaccordance with the definitions provided herein and in accordance withcommon knowledge in the art. In preferred embodiments, thesetherapeutically effective amounts are determined based on themeasurements and IDDM biomarkers disclosed in the Examples (e.g.,insulin, insulin auto-Abs, pancreatic auto-Abs).

In accordance with the definitions provided herein, the JAK inhibitor,or pharmaceutically acceptable salt or ester thereof, and theintravenous immunoglobulin; the JAK inhibitor, or pharmaceuticallyacceptable salt or ester thereof, and the therapeutic agent thatdestroys B lymphocytes; the intravenous immunoglobulin and thetherapeutic agent that destroys B lymphocytes; or the JAK inhibitor, orpharmaceutically acceptable salt or ester thereof, the intravenousimmunoglobulin and the therapeutic agent that destroys B lymphocytes maybe administered in combination with each other, i.e., as a combinationtherapy. These therapeutic agents may be administered concurrently with,prior to, or subsequent to, one another. It will be appreciated thattherapeutic agents utilized in combination may be administered togetherin a single composition or dosage unit or administered separately indifferent compositions or dosage units. In general, each therapeuticagent will be administered at a dose and/or with a dosing regimenoptimized for that particular therapeutic agent.

Also within the scope of the present invention are therapeutic regimensthat include not only one or more of a therapeutically effective amountof a Janus kinase inhibitor, or a pharmaceutically acceptable salt orester thereof, a therapeutically effective amount of intravenousimmunoglobulin, and/or a therapeutically effective amount of atherapeutic agent that destroys B lymphocytes, but additionally one ormore therapeutic agents. These additional therapeutic agents may be anadditional Janus kinase inhibitor, or pharmaceutically acceptable saltor ester thereof, intravenous immunoglobulin, and/or therapeutic agentthat destroys B lymphocytes. These additional therapeutic agents mayalso be therapeutic agents that are not a Janus kinase inhibitor, orpharmaceutically acceptable salt or ester thereof, intravenousimmunoglobulin, or therapeutic agent that destroys B lymphocytes. In oneembodiment of the present invention, these additional therapeutic agentsmay be therapeutic agents that are commonly used to treat IDDM, forexample insulin. In one embodiment of the present invention,administration of insulin to a subject, or treatment of the subject withinsulin, starts before the point in time when one or more oftofacitinib, IVIG and rituximab are administered to the subject, or whenthe subject is treated with one or more of tofacitinib, IVIG andrituximab, and continues even after this point in time. In oneembodiment of the present invention, administration of insulin to asubject, or treatment of the subject with insulin, continues, or starts,when administration of, or treatment with, one or more of tofacitinib,WIG and rituximab ceases.

In some embodiments of the present invention, the term “pharmaceuticallyacceptable” as used herein refers to agents that, within the scope ofthe sound medical judgment of the person having ordinary skill in theart, are suitable for use in contact with tissues of animals (e.g.,humans) without excessive toxicity, irritation, allergic response, orother problems or complications, commensurate with a reasonablebenefit/risk ratio.

In some embodiments of the present invention, the term “pharmaceuticallyacceptable carrier” as used herein refers to a pharmaceuticallyacceptable material, composition or vehicle, such as a liquid or solidfiller, diluent, or solvent that is part of a pharmaceutical compositionor dosage form containing a therapeutic agent. Some examples ofmaterials which can serve as pharmaceutically acceptable carriersinclude: sugars, such as lactose, glucose and sucrose; starches, such ascorn starch and potato starch; cellulose and its derivatives, such assodium carboxymethyl cellulose, ethyl cellulose and cellulose acetate;powdered tragacanth; malt; gelatin; talc; materials such as cocoa butterand suppository waxes; oils, such as peanut oil, cottonseed oil,safflower oil, sesame oil, olive oil, corn oil and soybean oil; glycols,such as propylene glycol; polyols, such as glycerin, sorbitol, mannitoland polyethylene glycol; esters, such as ethyl oleate and ethyl laurate;agar; buffering agents, such as magnesium hydroxide and aluminumhydroxide; alginic acid; pyrogen-free water; isotonic saline; Ringer'ssolution; ethyl alcohol; pH buffered solutions; polyesters;polycarbonates and/or polyanhydrides; and other non-toxic compatiblesubstances commonly employed in pharmaceutical formulations. As usedherein, the terms carrier and excipient have the same meaning and areused interchangeably.

In some embodiments of the present invention, the term “pharmaceuticallyacceptable salt(s)” refers to acid addition salts that retain thebiological effectiveness of the free bases and that are not biologicallyor otherwise undesirable. The manufacture, selection and use of suchacid addition salts is generally known by the person having ordinaryskill in the art. Such pharmaceutically acceptable acid addition saltsmay be formed with a number of different acids, which include, but arenot limited to, inorganic acids such as hydrochloric acid, hydrobromicacid, sulfuric acid, nitric acid, phosphoric acid, and the like, as wellas organic acids such as acetic acid, trifluoroacetic acid, propionicacid, hexanoic acid, heptanoic acid, cyclopentanepropionic acid,glycolic acid, pyruvic acid, lactic acid, malic acid, oxalic acid,maleic acid, malonic acid, succinic acid, fumaric acid, tartaric acid,citric acid, benzoic acid, cinnamic acid, mandelic acid, methanesulfonicacid, ethanesulfonic acid, p-toluenesulfonic acid, salicylic acid,stearic acid, and the like.

In some embodiments of the present invention, the term “pharmaceuticallyacceptable salt(s)” also refers to base addition salts that are notbiologically or otherwise undesirable. The manufacture, selection anduse of such base addition salts is generally known by the person havingordinary skill in the art. Such pharmaceutically acceptable baseaddition salts may be for example, but are not limited to, metallicsalts made from aluminum, calcium, lithium, magnesium, potassium, sodiumand zinc, or organic salts made from lysine,N,N′-dibenzylethylenediamine, chloroprocaine, choline, diethanolamine,ethylenediamine, meglumine (N-methylglucamine) and procaine. See, e.g.,Remington's Pharmaceutical Sciences, 18th eds., Mack Publishing, EastonPa. (1990) or Remington: The Science and Practice of Pharmacy, 19theds., Mack Publishing, Easton Pa. (1995).

The contents of all documents (scientific articles, patents, publishedpatent applications or other documents) cited herein are incorporatedherein by reference in their entirety.

The invention will be more fully understood by reference to thefollowing Examples. They should not, however, be construed as limitingthe scope of the invention.

EXAMPLES Example 1

A 14 years old male patient diagnosed with IDDM was treated with 8 unitsof exogenous long-acting insulin per day (administered in the evening)and 1 unit of short-acting insulin per 6 grams of carbohydrate foodintake (administered before each meal).

The patient was then treated twice-daily with a 5 mg dose of tofacitinib(calculated based on the weight of tofacitinib free base; correspondingto 8 mg of tofacitinib citrate) for a period of six months, using onetablet of the Xeljanz® immediate-release tofacitinib citrate tablet drugproduct twice-daily (BID). Starting three days post initiation oftofacitinib treatment, the patient did not receive any short-actinginsulin and was kept solely on long-acting insulin (8 units per day,administered in the evening). Starting three weeks post initiation oftofacitinib treatment, the patient did not receive any exogenousinsulin.

About six months post initiation of tofacitinib treatment, thetofacitinib dosing regimen was increased to 10 mg tofacitinib twicedaily (calculated based on the weight of tofacitinib free base;corresponding to 16 mg of tofacitinib citrate), using two tablets of theXeljanz® immediate-release tofacitinib citrate tablet drug producttwice-daily (BID). Specific stimulation high-carb diet was introducedoccasionally to monitor the patient's pancreatic ability to respond tothe glycemic demands.

At about 10 months post initiation of tofacitinib treatment, the patienthad gained overall weight and muscle mass. Since the patient's sugarlevels fluctuated and no further change of his auto-antibody bloodtiters was detected at this point (see Table 1 below), the patient wasadditionally treated with intravenous immunoglobulin (WIG) (Gamunex®-Cimmunoglobulin product from Grifols Therapeutics Inc.) at the dosagesand time points indicated in Tables 1-2 to further improve the patient'scondition. Each IVIG dose was administered in one continuous infusionsession. From week 16 to week 42, the patient was also treated withalpha one antitrypsin.

Throughout the patient's treatment, the patient's blood was drawn at thetime points indicated in Tables 1-2 below, and analyzed by establishedtesting laboratories with respect to standard IDDM blood parameters (seeTables 1-2, top row of each table listing the markers assayed; thenumerical values in parenthesis after some of the markers indicatenormal reference levels).

As can be seen, tofacitinib treatment and IVIG treatment had asynergistic effect. In particular, the data in Table 1 show a reductionin pancreatic islet-cell auto-antibodies and anti-insulinauto-antibodies upon treatment with tofacitinib. A further reduction canbe seen upon additional treatment with IVIG (see data points inleft-most two data-columns in Table 1).

Additionally, addition of anti-CD20 antibody agent “Rituxan”, givenintravenously to the patient showed a synergistic effect with thetofacitinib treatment and IVIG treatment. Rituxan and IVIGadministration was carried out according to the published regimen (Ahmedet al. New England Journal of Medicine 355:17 (2006)). The patient wasdosed at 750 mg intravenously on weeks 87, 88, 89 and 90. Comparing thepancreatic islet-cell auto-antibodies and anti-insulin auto-antibodiesupon treatment with tofacitinib in week 82.5 to the pancreaticislet-cell auto-antibodies and anti-insulin auto-antibodies upontreatment with tofacitinib with rituxan and IVIG in week 87.5, asignificant reduction can be seen.

The “date” columns in Tables 1-2 indicate the weeks post-tofacitinibtreatment initiation that further treatment was administered to thepatient, and the points in time when the patient's bloodwork was done.The patient's 8 mg tofacitinib citrate BID treatment regimen (asdescribed) started in week zero and ended 25 weeks later (see Tables1-2). The patient's 16 mg tofacitinib citrate BID treatment regimen (asdescribed) started in week 25 and is still ongoing with an exception inweeks 77-79 (see Tables 1-2). Tables 1 and 2 describe the same treatmentbut include data points with respect to different markers tested.

TABLE 1 data points IA2 Ab treatment Insulin (Islet cell tofacitinibAuto Ab Ab Screen) Islet Cell date citrate IVIG (<0.4) (<0.8) Ab TitersGlucose week −3 — — 6.8 — 80 519 week −0.5 — — 47   160   — — week 0  8mg BID — — — — — week 4 — 7.2 43.8 — — week 9 — — — — — week 10 —64   >50   — — week 13 — 6.1 46.2 320  104 week 19 — 6.6 37.7 80 126week 22 — 4   — negative 210 week 25 — 5.3 — 20 — week 25.5 — — — — —week 26 — 5   47.3 negative  93 week 29 — 4.6 47.7 20  85 week 30 — 4.243.8 — 143 week 36 — 2.4 46.5 20 — week 44 16 mg BID 2 mg/Kg = 150 — — —— (day 1) mg total infusion of IVIG week 44 1 mg/Kg = 75 — — — — (day 2)mg total infusion of IVIG week 44 1 mg/Kg = 75 — — — — (day 3) mg totalinfusion of IVIG week 47 — 2.1 17   negative — week 47.5 1 mg/Kg = 75 —— — — mg total infusion of IVIG week 50 — 0.9 35.7 negative — week 50.51 mg/Kg = 75 — — — — mg total infusion of IVIG week 53 — 0.8 30  negative  97 week 54 1 mg/Kg = 75 — — — — mg total infusion of IVIG week57 — 1   25.9 negative 168 week 61 — 0.9 39.4 negative 160 week 66 — 0.938.8 negative week 70 — 1.7 39.4 negative 112 week 75 — 0.7 39.2negative 113 week 77 5 mg QAM & — — — — — week 79 10 mg QHS — 0.5 44.5negative  85 week 82 10 mg BID — — — — — week 82.5 — 0.5 46   negative230 week 86 2 gm/Kg — — — — week 86.15 1 gm/Kg week 86.30 1 gm/Kg week87.5 — <0.4   6.5 negative 278 week 89 1 gm/Kg — — — — week 91.25 —<0.4  13.1 negative 148 week 92.25 — 0.5 25.6 negative 148 week 99.25 —0.7 26.5 20 170

TABLE 2 treatment data points tofacitinib C-Peptide Insulin GAD-65Tyrosine date citrate IVIG (0.8-3.85) (2-19.6) HgbA1C (<5) (31-108) week−3 — — 0.6  3.8 13.6  — — week −0.5 — — 1.08 27 — <5 116  week 0  8 mgBID — — — — — — week 4 — 2.66 17.1 — — 79 week 9 — 1.5  7.8 7.2 — 90week 10 — 4.7  34.5 — — — week 13 — 1.43 — — — 74 week 19 — 1.79 12 6.1<5 83 week 22 — — 24.8 6.1 — — week 25 — — — — — — week 25.5 16 mg BID —— — — — — week 26 — 2.19 12 — <5 91 week 29 — 1.34 5.4 6.2 — — week 30 —2.74 34.3 6.3 <5 — week 36 — 3.17 31.1 — — — week 44 2 mg/Kg — — — — —(day 1) week 44 1 mg/Kg — — — — — (day 2) week 44 1 mg/Kg — — — — — (day3) week 47 — — — 6.9 — — week 47.5 1 mg/Kg = 75 — — — — — mg totalinfusion of IVIG week 50 — 2.73 25 6.5 — — week 50.5 1 mg/Kg = 75 — — —— — mg total infusion of IVIG week 53 — 2.14 14.8 6.5 66 75 week 54 1mg/Kg = 75 — — — — — mg total infusion of IVIG

Example 2

A patient (appr. 60 kg) diagnosed with IDDM is treated with acombination of tofacitinib and IVIG at the following doses for a periodof three months:

(1) 16 mg tofacitinib citrate twice-daily (equivalent to 10 mgtofacitinib free base), using the Xeljanz® immediate-release tofacitinibcitrate tablet drug product from Pfizer (each tablet including 8 mg oftofacitinib citrate, equivalent to 5 mg tofacitinib free base); and

(2) a loading dose of 2 mg IVIG/Kg subject body weight on the first dayof treatment followed by doses of 1 mg IVIG/Kg on the second and thirdday. This is followed by maintenance doses of 1 mg IVIG/Kg every threeweeks. The Gamunex®-C immunoglobulin product from Grifols TherapeuticsInc. is used.

Three months after treatment initiation, the patient is treated foranother three weeks with a combination tofacitinib/IVIG as before andadditionally 375 mg/m² rituximab once per week for three weeks.

Afterwards, rituximab is discontinued and the IVIG is continued at thesame dose (i.e., maintenance doses of 1 mg/Kg every three weeks) foranother two months, and then discontinued. Tofacitinib is continued atthe same dose (i.e., 16 mg BID (equivalent to 10 mg tofacitinib freebase)).

Once the patient's blood glucose levels and blood levels of insulin andpancreatic and insulin autoantibodies return to normal, tofacitinibdoses are gradually reduced. Tofacitinib treatment is then eitherdiscontinued in case there is no need for further treatment, ormaintained at the lowest level that can control the patient's glucoselevels. Blood tests are performed once every three months over a periodof two years to assure that the patient's glucose levels and levels ofinsulin and pancreatic and insulin autoantibodies remain normal.

In parallel to the aforesaid therapeutic regimen, the patient may alsoreceive exogenous insulin. Exogenous insulin may also be administeredafter the administration of one or more of tofacitinib, IVIG andrituximab has been discontinued.

Example 3

A patient is treated for IDDM with tofacitinib. The patient alsoreceives IVIG for the treatment of IDDM. On the first three days oftreatment with WIG, 2, 1 and 1 mg IVIG/Kg subject body weight areadministered, respectively. Then, the patient receives 1 mg IVIG/Kgsubject body weight three weeks after the aforesaid dose on day three,and another 1 mg IVIG/Kg subject body weight dose three weeks later. Oneday after the last WIG dose, the patient receives a dose of rituximaband then two more rituximab doses at one week intervals. Right after thethird rituximab dose, the patient receives another 1 mg IVIG/Kg subjectbody weight dose, and then a last 1 mg IVIG/Kg subject body weight dosethree weeks later. The patient continues to receive tofacitinib.

What is claimed is:
 1. A method of treating insulin-dependent diabetesmellitus in a subject, comprising administering to the subject atherapeutically effective amount of a Janus kinase inhibitor, or apharmaceutically acceptable salt or ester thereof, or a therapeuticallyeffective amount of intravenous immunoglobulin, or a therapeuticallyeffective amount of a therapeutic agent that destroys B lymphocytes, ora combination thereof.
 2. The method of claim 1, wherein the Januskinase inhibitor, or a pharmaceutically acceptable salt or esterthereof, is selected from the group consisting of a JAK1/3 inhibitor anda JAK3 inhibitor.
 3. The method of claim 2, wherein the Janus kinaseinhibitor, or a pharmaceutically acceptable salt or ester thereof, istofacitinib.
 4. The method of claim 3, wherein the Janus kinaseinhibitor, or a pharmaceutically acceptable salt or ester thereof, istofacitinib citrate.
 5. The method of claim 1, wherein the therapeuticagent that destroys B lymphocytes is an antibody agent.
 6. The method ofclaim 5, wherein the antibody agent is an anti-CD20 antibody agent. 7.The method of claim 6, wherein the anti-CD20 antibody agent comprisesamino acid sequences substantially identical to the CDRs of rituximab.8. The method of claim 4, wherein tofacitinib citrate is administeredorally.
 9. The method of claim 8, wherein tofacitinib citrate isadministered as a tablet.
 10. The method of claim 9, wherein the tabletis an immediate-release tablet, comprising one or more binders, or oneor more diluents, or one or more disintegrants, or one or morelubricants, or combinations thereof.
 11. The method of claim 10, whereinthe immediate-release tablet comprises about 8 mg tofacitinib citrate.12. The method of claim 9, wherein the tablet is an extended-releasetablet, comprising one or more binders, or one or more diluents, or oneor more disintegrants, or one or more lubricants, or combinationsthereof.
 13. The method of claim 12, wherein the extended-release tabletcomprises about 17.77 mg tofacitinib citrate.
 14. The method of claim 1,wherein the intravenous immunoglobulin is administered as a sterilesolution for injection comprising from 9%-11% protein in 0.16-0.24 Mglycine.
 15. The method of claim 4, wherein tofacitinib citrate isadministered at a dose of 8 or 16 mg twice daily.
 16. The method ofclaim 1, wherein the intravenous immunoglobulin is administered at adose of 1 to 2 mg per kg weight of the subject every 1 to 3 weeks.
 17. Akit for the treatment of insulin-dependent diabetes mellitus in asubject, comprising a Janus kinase inhibitor, or a pharmaceuticallyacceptable salt or ester thereof, and intravenous immunoglobulin. 18.The kit of claim 17, further comprising a therapeutic agent thatdestroys B lymphocytes.
 19. The kit of claim 17, wherein the Januskinase inhibitor, or a pharmaceutically acceptable salt or esterthereof, is tofacitinib citrate; and wherein the therapeutic agent thatdestroys B lymphocytes is rituximab.
 20. A kit for the treatment ofinsulin-dependent diabetes mellitus in a subject, comprising intravenousimmunoglobulin and a therapeutic agent that destroys B lymphocytes.